tag:theconversation.com,2011:/id/topics/general-practitioners-12946/articlesgeneral practitioners – The Conversation2024-03-06T17:15:01Ztag:theconversation.com,2011:article/2244272024-03-06T17:15:01Z2024-03-06T17:15:01ZGeneral practice is in crisis in the UK – and it’s failing the people who need it most<figure><img src="https://images.theconversation.com/files/579216/original/file-20240301-28-25c0vz.jpg?ixlib=rb-1.1.0&rect=14%2C22%2C4969%2C3295&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-giving-checkup-woman-exam-room-14464498">Monkey Business Images/Shutterstock</a></span></figcaption></figure><p>There is <a href="https://www.bmj.com/content/381/bmj.p966">no doubt</a> that <a href="https://www.theguardian.com/society/2022/nov/20/gps-in-england-treat-up-to-three-times-more-patients-than-safety-limit-demands">primary care</a> in the UK – the services that provide the first point of contact in the healthcare system, such as general practice – isn’t working.</p>
<p><a href="https://www.telegraph.co.uk/news/2023/11/12/gps-elusive-species-elderly-patients-phone-appointments/">Patients report</a> <a href="https://inews.co.uk/news/health/patients-struggle-gp-appointments-collapse-nhs-1742850">difficulties in making appointments</a> and seeing the same GP. <a href="https://www.rcgp.org.uk/getmedia/11f26527-5d11-47f2-a593-1a894c2fff1b/Continuity-of-care-in-modern-day-general-practice1.pdf">Continuity of care</a> is an important factor in patient outcomes, particularly for older adults with comorbidities – those living with more than one long-term condition, such as diabetes or asthma. </p>
<p><a href="https://www.telegraph.co.uk/news/2024/02/23/seeing-the-same-gp-fewer-visits-to-the-doctor/#:%7E:text=Patients%20who%20see%20the%20same,to%20return%20after%20shorter%20periods.">Research shows</a> that patients who see the same doctor have fewer hospital admissions and lower mortality rates. However, we also know that <a href="https://www.theguardian.com/society/2024/mar/04/worst-off-find-it-harder-than-well-off-to-access-nhs-care-survey-finds">people on the lowest incomes</a> have much more difficulty getting GP appointments. And when they do, they are much more likely to have a <a href="https://www.england.nhs.uk/about/equality/equality-hub/national-healthcare-inequalities-improvement-programme/what-are-healthcare-inequalities/deprivation/">much worse experience</a> than those who’re more financially comfortable. </p>
<p>Evidence shows that, in particular, older adults who live in poorer areas <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5839575/">struggle to access</a> the primary care that they need. They already have poorer health outcomes, and their life expectancy is lower those living in more affluent areas – yet GP services are not providing the help they should.</p>
<p>Access to <a href="https://www.bmj.com/content/375/bmj.n2916/rr">general practice is vital</a> to maintaining good public health. It’s the entry point to the national health care system, and <a href="https://blogs.bmj.com/bmj/2021/05/14/if-general-practice-fails-the-nhs-fails/">accounts for around 90%</a> of all patient contact with the NHS. </p>
<p>But overall patient satisfaction with general practice <a href="https://www.bmj.com/content/378/bmj.o1764">seems to be in sharp decline</a>. Between 2021 and 2023, the percentage of patients <a href="https://www.kingsfund.org.uk/insight-and-analysis/reports/public-satisfaction-nhs-and-social-care-2022#key-findings">reporting a good overall experience</a> fell from <a href="https://www.england.nhs.uk/statistics/2023/07/13/gp-patient-survey-2023/">71% to 55%</a>. </p>
<p>The reasons for this apparent <a href="https://bmjopen.bmj.com/content/9/2/e026048">crisis in confidence</a> have been covered widely in the media. But reports have tended to focus on GPs rather than the patients who’re most affected. </p>
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<p>For example, it’s been widely reported that the <a href="https://www.rcgp.org.uk/getmedia/155e72a9-47b9-4fdd-a322-efc7d2c1deb4/retaining-gp-workforce-report.pdf">number of GPs</a> <a href="https://researchbriefings.files.parliament.uk/documents/CBP-9731/CBP-9731.pdf">has fallen 4%-5%</a> in recent years and <a href="https://bjgplife.com/stressed-overworked-and-dissatisfied-the-unholy-trio-of-general-practice-in-the-uk/">many doctors</a> who remain in general practice report <a href="https://www.health.org.uk/publications/reports/stressed-and-overworked">feeling stressed and over-worked</a>. It’s no wonder, then, that a significant proportion of <a href="https://www.gponline.com/half-gps-cut-working-hours-ease-workload-poll-shows/article/1811685">GPs have opted to reduce</a> their hours.</p>
<p>There <a href="https://publications.parliament.uk/pa/cm5803/cmselect/cmhealth/113/summary.html">aren’t enough</a> general practitioners <a href="https://www.theguardian.com/commentisfree/2022/jul/03/the-observer-view-on-britain-gp-shortage">to meet growing demand</a>, especially for the <a href="https://www.rcgp.org.uk/getmedia/3613990d-2da8-458a-b812-ed2cf6d600a6/RCGP-Brief_GP-Shortages-in-England.pdf">complex needs of an aging population</a>.</p>
<p>But what of the people disproportionately affected by the crisis in general practice? </p>
<h2>Older, impoverished adults disproportionately affected</h2>
<p>As life expectancy in the <a href="https://www.kingsfund.org.uk/insight-and-analysis/long-reads/whats-happening-life-expectancy-england">UK increases</a>, the <a href="https://www.england.nhs.uk/ourwork/clinical-policy/older-people/improving-care-for-older-people/">role of general practice</a> in keeping people well and living independently <a href="https://www.msdmanuals.com/home/older-people%E2%80%99s-health-issues/providing-care-to-older-people/continuity-of-care">is crucial</a>. This is particularly true in older patients with comorbidities. The often complex nature of their conditions means that these patients need regular monitoring and access to GP services. </p>
<p>In addition, older adults with comorbidities are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9385725/">often socially isolated</a>, and the human contact provided by the therapeutic relationship developed through regular appointments is <a href="https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-019-1189-9">considered vital</a> to their wellbeing. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6853241/">Research has highlighted</a> that the <a href="https://www.health.org.uk/publications/long-reads/measuring-continuity-of-care-in-general-practice">ongoing relationship</a> between GP and patient is particularly important in this group of patients. </p>
<p>However, the <a href="https://www.qmul.ac.uk/media/news/2022/smd/seeing-the-same-gp-is-good-for-your-health-but-only-half-of-patients-are-able-to-do-so.html">continuity of care</a> traditionally provided by the family doctor has declined as primary care struggles to meet the demands placed upon it. In these situations, the influence of <a href="https://patient.info/doctor/health-and-social-class">education and social class</a> on health becomes increasingly apparent. </p>
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<p>A 2024 survey by NHS watchdog <a href="https://www.healthwatch.co.uk/what-we-do">Healthwatch</a> found that already well established links between poverty and ill health are exacerbated by barriers to obtaining healthcare. </p>
<p>The report, which surveyed a representative sample of the population – 2,018 people aged over-16 in England – found that those in poverty were twice as likely to experience problems getting to see a GP than those who identified as “very comfortable” financially. </p>
<p>Louise Ansari, Healthwatch’s chief executive, suggested that the <a href="https://www.theguardian.com/society/2024/mar/04/worst-off-find-it-harder-than-well-off-to-access-nhs-care-survey-finds">survey’s findings</a> were a warning that the NHS could be moving toward a <a href="https://www.telegraph.co.uk/news/2023/10/20/nhs-care-quality-commission-report-health-service/">“two-tier service”</a> with ease of access closely related to wealth. </p>
<p>Ansari’s concerns seem to be well-founded. In more affluent, middle class areas, the quality of general practice is often better and <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthcaresystem/articles/trendsinpatienttostaffnumbersatgppracticesinengland/2022">more readily available</a>, often because practices have fewer patients. </p>
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<p>Wealthier areas tend to have <a href="https://www.ons.gov.uk/visualisations/censusworkforcequalifications/">more highly educated populations</a>, who tend to be more confident in requesting appointments and articulating their health concerns. </p>
<p>Conversely, people living in <a href="https://theconversation.com/gp-crisis-how-did-things-go-so-wrong-and-what-needs-to-change-208197">less affluent areas</a> with greater levels of deprivation may not always be aware of what they are entitled to, or how to get it. </p>
<h2>Delays in seeking help</h2>
<p>The move to remote consultations is another aspect of the barriers to access faced by those who’re most socially and financially disadvantaged.</p>
<p>While remote consultation <a href="https://bmjopen.bmj.com/content/13/5/e070923">may be appropriate</a> and perfectly satisfactory, even preferable, for many patients, there are people – often from the <a href="https://digitalpovertyalliance.org/uk-digital-poverty-evidence-review-2022/introduction-myths-and-shifts/">most deprived groups</a> – who are <a href="https://www.kingsfund.org.uk/insight-and-analysis/long-reads/exclusion-inclusion-digital-health-care#:%7E:text=Groups%20commonly%20considered%20digitally%20excluded,areas%2C%20people%20from%20low%20socio%2D">digitally excluded</a> (unable to use the internet in ways that are needed to participate fully in modern society) and do not have the resources to access virtual appointments. </p>
<p>But this <a href="https://www.gov.uk/government/news/new-plan-to-make-it-easier-for-patients-to-see-their-gp">lack of easy access</a> for all patients is at odds with public health messaging. </p>
<p>For example, <a href="https://digital.nhs.uk/ndrs/our-work/ncras-work-programme/cancer-awareness-campaigns#:%7E:text=Resources-,Introduction,to%20see%20their%20GP%20sooner">public health campaigns</a> that target older adults, emphasise the importance of early detection of cancer: “<a href="https://www.england.nhs.uk/2022/03/celebrities-join-forces-with-the-nhs-to-encourage-cancer-checks/">if something doesn’t feel quite right … get it checked out”</a>. <a href="https://pubmed.ncbi.nlm.nih.gov/35298272/">Early detection and survival rates</a> in all types of cancer are inextricably linked.</p>
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<p>However, difficulty accessing a GP appointment means that <a href="https://www.bbc.co.uk/news/health-37605573">people are more likely to put off</a> and delay seeking help with their symptoms. The number of <a href="https://www.bmj.com/company/newsroom/every-month-delayed-in-cancer-treatment-can-raise-risk-of-death-by-around-10/">late presentations for cancer</a> in particular means that long term survival rates from cancer are not as good as they should be. </p>
<p>The UK’s ageing population and the recent sharp rise in the cost of living means the number of disadvantaged older people in need of consistent, high quality GP care is rising. But their chance of getting it seems to be ever dwindling.</p><img src="https://counter.theconversation.com/content/224427/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robin Lewis does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Older adults in poorer areas would benefit more from seeing the same GP, but often find continuous primary care harder to access.Robin Lewis, Senior Lecturer in Healthcare, Sheffield Hallam UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2061832023-07-17T20:02:39Z2023-07-17T20:02:39ZShould you register with a GP? What is MyMedicare and how might it change the care you get?<figure><img src="https://images.theconversation.com/files/533371/original/file-20230622-8583-mxjvpt.jpg?ixlib=rb-1.1.0&rect=7%2C22%2C4977%2C3295&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/british-gp-examining-young-child-mother-98508353">Shutterstock</a></span></figcaption></figure><p><a href="https://www.health.gov.au/our-work/mymedicare">MyMedicare</a> is a new voluntary scheme that allows patients to register with their usual GP, in an attempt to improve continuity of care and health outcomes.</p>
<p>From October 1, the scheme will give registered patients access to longer telehealth consultations. Then, from next year, GP clinics with patients who are frequently admitted to hospital or are aged care residents will be able to access additional “blended” funding, which sits outside Medicare’s usual fee-for-service. </p>
<p>MyMedicare was announced in the May budget, with A$19.7 million of funding over four years, alongside a range of <a href="https://www.health.gov.au/sites/default/files/2023-05/building-a-stronger-medicare-budget-2023-24_0.pdf">other health reforms</a>, including funding for practice nurses to improve team-based care, as well as new incentives to increase bulk billing rates. </p>
<p>We’re still waiting on a lot of detail about how the scheme will function. But here’s what we know so far – and what it might mean for patients and GPs. </p>
<h2>What do we know about MyMedicare?</h2>
<p>The scheme is voluntary for GPs and patients. In addition to patients opting in, GPs will also need to sign up, and have been able to do so since the start of July. There will be a gradual roll out and it will take three years to cover all of Australia. </p>
<p>Though details are yet to be confirmed, from mid-2024 individual GPs will receive “<a href="https://www.acponline.org/about-acp/about-internal-medicine/career-paths/residency-career-counseling/resident-career-counseling-guidance-and-tips/understanding-capitation">capitation</a>” payments for patients who have more than ten hospital admissions per year. These patients are likely to have complex needs and multiple conditions and, for various reasons, may not be able to access a GP as much as they should. </p>
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Read more:
<a href="https://theconversation.com/health-budget-has-big-changes-reviving-our-worn-out-medicare-fee-for-service-system-and-boosting-bulk-billing-204527">Health budget has big changes – reviving our worn-out Medicare fee-for-service system and boosting bulk billing</a>
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<p>Though not yet confirmed, GPs are likely to <a href="https://www.ausdoc.com.au/news/the-mymedicare-enrolment-scheme-is-open-for-gp-practices-should-you-sign-up-now/">receive</a> $2,000 per patient per year, plus a $500 bonus for keeping patients out of hospital. The funding provides incentives for the GP to coordinate their care and provide the patient with access to nursing and allied health if required. It’s hoped this will stop patients going to hospital as often.</p>
<p>There will also be similar payments for providing regular visits to patients in residential aged care facilities. </p>
<h2>Will MyMedicare make a difference to patients?</h2>
<p>Let’s consider four key areas patients are concerned about: </p>
<p><strong>1) Continuity of care</strong></p>
<p>Research shows greater <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2753.2009.01235.x">continuity of care</a> – developing a relationship with and seeing the same provider or team for your care – improves patient outcomes and reduces costs to the health system. People who use MyMedicare to get a regular GP may see some of these benefits.</p>
<p>But many patients already see the same GP or visit the same practice, especially those with chronic conditions. So registration with a practice may not make much difference for this group of patients. What are the other benefits of registration? </p>
<p><strong>2) Reducing hospital admissions</strong></p>
<p>Avoiding hospitals can be beneficial – in hospitals, there are no home comforts, they are inconvenient for you and relatives, there is little privacy, and they can be costly. Patients with ten or more hospital admissions in a year have been targeted as they have more complex chronic conditions and may be from vulnerable populations. </p>
<p>Better access to a GP could prevent patients visiting the emergency department or prevent overnight hospital admissions. Research shows financial incentives for GPs to better manage chronic disease <a href="https://journals.sagepub.com/doi/full/10.1177/01410768211005109">can reduce hospital admissions</a>. </p>
<p>However, <a href="https://bmjopen.bmj.com/content/5/4/e007342?cpetoc=&int_source=trendmd&int_medium=trendmd&int_campaign=trendmd">hospital admissions could also increase</a> if the scheme identifies significant levels of previous unmet need.</p>
<p><strong>3) Reducing barriers to care</strong></p>
<p>MyMedicare does not directly address many of the <a href="https://link.springer.com/article/10.1186/1475-9276-12-18">barriers to accessing GP services</a>. If GPs are getting paid more and still getting fee for service payments, will MyMedicare patients be guaranteed to be bulk billed? This has not yet been mentioned, but could be an important part of the scheme to attract patients. </p>
<p>People with chronic disease have <a href="https://grattan.edu.au/report/not-so-universal-how-to-reduce-out-of-pocket-healthcare-payments/">two to three times higher</a> out-of-pocket costs than those who do not, and <a href="https://healthsystemsustainability.com.au/the-voice-of-australian-health-consumers/">30%</a> of patients with chronic disease would find it difficult to pay for care if they became seriously ill. </p>
<p>Unfortunately MyMedicare will not directly reduce out-of-pocket costs, which may be the real reason why people use “free” emergency department care.</p>
<p><strong>4) Making it clear and easy to sign up</strong></p>
<p>It is also unclear how the process of registration will work for patients. Will patients be offered a choice of alternative GPs? If chosen, will GPs be obliged to take them? </p>
<p>At the moment, there are no public data about out-of-pocket costs and quality of care provided by different GPs, and so it will be impossible for patients to make an informed choice. Information to inform choice on a website would be useful, as is the case for <a href="https://www.health.gov.au/resources/apps-and-tools/medical-costs-finder">specialists</a>. </p>
<p>It’s also unclear if patients who chose to register will find it harder to move GPs or continue to see other GPs if they wish to. The advantages to patients of MyMedicare need to be made clear to encourage them to register and be supported to exercise informed choice if they wish.</p>
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Read more:
<a href="https://theconversation.com/if-you-live-in-a-bulk-billing-desert-its-hard-to-see-a-doctor-for-free-heres-how-to-fix-this-204029">If you live in a bulk-billing ‘desert’ it's hard to see a doctor for free. Here's how to fix this</a>
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<h2>Will it make a difference for GPs?</h2>
<p>Patient registration can mean a more secure and predictable stream of future income for some patients and also less competition (in terms of “losing” patients to other GPs) and more continuity of care. </p>
<p>Moving away from fee for service towards a blended payment model is <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011865.pub2/full">widely recognised</a> to support higher value health care. </p>
<p>Yet GPs are wary of moving from fee for service to capitation payment. Capitation payments are fixed, so GPs take on more financial risk if they have more complex patients who are more costly to treat and manage in terms of time and effort. Whether the $2,000, plus $500 bonus, plus normal fee for service payments are sufficient to cover the costs of treating very complex patients is unclear. </p>
<p>Overall, GPs will get more money, and along with the other announcements in the budget, will receive a significant investment of resources invested in primary care. </p>
<p>Our previous <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/hec.3572">research</a> has shown a 5% increase in earnings for GPs is predicted to reduce the total number of GPs by up to 1% (equivalent to around 310 GPs in 2021) at a time of significant GP shortages. If they get paid more, they would prefer to work less.</p>
<p>But this could also be offset because the increase in funding will hopefully make general practice more attractive as a career and so there will be more postgraduate doctors <a href="https://www.sciencedirect.com/science/article/pii/S0167629612000902">choosing to be a GP</a>. </p>
<p>Voluntary patient registration under MyMedicare has potential to strengthen the relationship between patients and their GP, and focuses on keeping patients out of hospital and properly cared for in residential aged care. But the devil is in the detail and we will need a proper evaluation to determine the impacts on health outcomes, costs and access to health care. </p>
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Read more:
<a href="https://theconversation.com/what-if-medicare-was-restricted-to-gps-who-bulk-billed-this-kind-of-reform-is-possible-203543">What if Medicare was restricted to GPs who bulk billed? This kind of reform is possible</a>
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<img src="https://counter.theconversation.com/content/206183/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anthony Scott receives funding from the Australian Research Council, Medibank Better Health Foundation, and the Independent Hospital and Aged Care Pricing Authority.</span></em></p>MyMedicare is a new voluntary scheme that allows patients to register with their usual GP. How will it work? And how might it benefit patients? Here’s what we know so far.Anthony Scott, Professor of Health Economics, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1995952023-03-08T00:19:08Z2023-03-08T00:19:08ZMy kids are behind with their vaccines. How do they catch up?<figure><img src="https://images.theconversation.com/files/511564/original/file-20230222-20-7ndkjm.jpg?ixlib=rb-1.1.0&rect=0%2C7%2C1000%2C657&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/father-baby-girl-home-sleeping-1069794509">Shutterstock</a></span></figcaption></figure><p>The vast majority of Australian children are up-to-date with their vaccines. But vaccination rates have <a href="https://ncirs.org.au/sites/default/files/2022-12/Coverage%20report%202021%20SUMMARY%20FINAL.pdf">dipped slightly</a> over the past few years.</p>
<p>Fewer health checks, reduced access to routine health care during lockdowns, and fear of COVID have been the <a href="https://www.tandfonline.com/doi/full/10.1080/07853890.2021.2009128">main reasons</a>.</p>
<p>If that’s been the situation for your family, you can still catch up. Here’s how to check which vaccines are due for your children and how to organise appointments.</p>
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Read more:
<a href="https://theconversation.com/needles-are-nothing-to-fear-5-steps-to-make-vaccinations-easier-on-your-kids-153639">Needles are nothing to fear: 5 steps to make vaccinations easier on your kids</a>
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<h2>Which shots are due?</h2>
<p>If you are unsure which vaccines are given at different ages:</p>
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<li><p><strong>look up the vaccine schedule</strong>, officially called the National Immunisation Program Schedule. <a href="https://www.health.gov.au/resources/publications/national-immunisation-program-schedule?language=en">This lists</a> the recommended free vaccines at various ages</p></li>
<li><p><strong>download a vaccine scheduling app</strong>. Some states <a href="https://www.health.nsw.gov.au/immunisation/app/Pages/default.aspx">have an app</a> you can download to create a personal vaccine schedule for your children, with reminders of what’s due and when</p></li>
<li><p><strong>chat to your GP</strong>. The next time you see a GP (for any reason), you can ask about vaccines and which ones are due.</p></li>
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Read more:
<a href="https://theconversation.com/health-check-are-you-up-to-date-with-your-vaccinations-116510">Health Check: are you up to date with your vaccinations?</a>
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<h2>I think we’re behind. How do I check?</h2>
<p>If you think your child has missed a shot but want to check, obtain your child’s <a href="https://www.servicesaustralia.gov.au/how-to-get-immunisation-history-statement?context=22436">immunisation history statement</a> using:</p>
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<li><p>your Medicare online account through myGov or</p></li>
<li><p>the Medicare app.</p></li>
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<p>You can also call the <a href="https://www.health.gov.au/contacts/australian-immunisation-register-contact">Australian Immunisation Register</a> (1800 653 809) and ask for your child’s immunisation history statement to be sent to you. This can take up to 14 days to arrive in the post. </p>
<p>If your child is over the age of 14, they can get their immunisation history statements themselves.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/511607/original/file-20230222-24-mgzkrt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Teenager sitting in front of laptop" src="https://images.theconversation.com/files/511607/original/file-20230222-24-mgzkrt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/511607/original/file-20230222-24-mgzkrt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/511607/original/file-20230222-24-mgzkrt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/511607/original/file-20230222-24-mgzkrt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/511607/original/file-20230222-24-mgzkrt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/511607/original/file-20230222-24-mgzkrt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/511607/original/file-20230222-24-mgzkrt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Some teenagers can access their own immunisation records.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/asian-girls-sitting-stressed-studying-online-2007572123">Shutterstock</a></span>
</figcaption>
</figure>
<p>If you’re not eligible for Medicare, you can still get your immunisation history statement online <a href="https://www.servicesaustralia.gov.au/how-to-get-immunisation-history-statement?context=22436#a2">through myGov</a>. </p>
<p>In very rare cases, a vaccine may have been given but not recorded on the Australian Immunisation Register. </p>
<p>If you think this may be the case, check your child’s baby health book, as information may have been recorded there. You may also need to check with the GP who gave the vaccine. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/getting-vaccinated-at-the-pharmacy-make-sure-its-recorded-properly-140070">Getting vaccinated at the pharmacy? Make sure it's recorded properly</a>
</strong>
</em>
</p>
<hr>
<h2>OK, we are behind. What now?</h2>
<p>If there are no written records available of past vaccination, your child will be offered catch-up vaccines appropriate for their age.</p>
<p>But children who missed their recommended vaccines in childhood can also still receive them free <a href="https://www.health.gov.au/topics/immunisation/immunisation-information-for-health-professionals/catch-up-immunisations#who-can-get-free-catchup-immunisations">before they turn 20</a>. </p>
<p>Depending on the child’s age, you can go to your local doctor, pharmacy, hospital immunisation clinic, local council or see a community health nurse. </p>
<p>Find your local health service <a href="https://www.healthdirect.gov.au/australian-health-services">using this search engine</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/no-combination-vaccines-dont-overwhelm-kids-immune-systems-82377">No, combination vaccines don't overwhelm kids' immune systems</a>
</strong>
</em>
</p>
<hr>
<h2>I may need an interpreter</h2>
<p>Catch-up vaccinations are free. But we understand that families who speak a language other than English can face challenges navigating the health system, including <a href="https://www.publish.csiro.au/PY/PY10065">accessing vaccines</a>. </p>
<p>If this applies to your family, or someone you know, you or they can use an interpreter to talk to the GP about catch-up vaccinations. </p>
<p>This is a <a href="https://www.tisnational.gov.au/en/Non-English-speakers/Frequently-Asked-Questions">free phone service</a>, covering more than 150 different languages. Call 131 450.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/nearly-1-in-4-of-us-arent-native-english-speakers-in-a-health-care-setting-interpreters-are-essential-115125">Nearly 1 in 4 of us aren't native English speakers. In a health-care setting, interpreters are essential</a>
</strong>
</em>
</p>
<hr>
<h2>I have a large family. Any tips?</h2>
<p>If you have multiple children, the GP or practice nurse will tell you how many appointments you will need to ensure your children are up-to-date with their vaccines.</p>
<p>Here are some tips to help things run smoothly:</p>
<ul>
<li><p><strong>bring an extra adult</strong> (if possible) to sit outside the clinic with children not being immunised. This reduces the risk of distractions in the clinic</p></li>
<li><p><strong>try to ring ahead</strong> to let the GP surgery know they need catch-up vaccines. This allows the team time to work out a catch-up schedule</p></li>
<li><p>if you have records of vaccines given overseas speak to the surgery about <strong>dropping records in before</strong> the appointment. Again, this will allow the nurse to work out the catch-up schedule before you arrive</p></li>
<li><p>in some situations, you may be able to have <strong>slightly longer gaps between vaccines</strong> to reduce the number of visits needed. This will depend on the situation. The GP or practice nurse will be able to determine if this is possible based on what vaccines are needed.</p></li>
</ul>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/511611/original/file-20230222-20-ecgesk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Family with 4 children sitting on sofa" src="https://images.theconversation.com/files/511611/original/file-20230222-20-ecgesk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/511611/original/file-20230222-20-ecgesk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/511611/original/file-20230222-20-ecgesk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/511611/original/file-20230222-20-ecgesk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/511611/original/file-20230222-20-ecgesk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/511611/original/file-20230222-20-ecgesk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/511611/original/file-20230222-20-ecgesk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Large family? Ring ahead.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/portrait-photo-arab-muslim-family-sitting-2075149054">Shutterstock</a></span>
</figcaption>
</figure>
<h2>How about flu or COVID shots?</h2>
<p>Beyond the vaccines on the National Immunisation Program, some children are also recommended a flu and COVID shot, depending on their age.</p>
<p>Children aged 6 months and older are also recommended to receive a yearly influenza vaccine (free for kids <a href="https://www.health.gov.au/campaigns/influenza-vaccination-for-children-under-5">6 months to under 5 years</a>). If they are <a href="https://www.health.nsw.gov.au/news/Pages/20200316_01.aspx">older than 10 years</a>, they can get this flu vaccine at either a GP clinic or pharmacy. </p>
<p>COVID vaccination is currently recommended for children aged 6 months up to 5 years only if children have <a href="https://www.health.gov.au/news/atagi-recommendations-on-covid-19-vaccine-use-in-children-aged-6-months-to">special medical or other needs</a>, including a very weak immune system, disability, or complex or multiple health conditions. </p>
<p>Most children aged 5-17 years are recommended to have <a href="https://www.health.gov.au/our-work/covid-19-vaccines/who-can-get-vaccinated/children#who-is-eligible">two doses</a> of a COVID vaccine. </p>
<p>If your child has not received a COVID vaccine and you want some help deciding, there’s <a href="https://www.ncirs.org.au/covid-19-decision-aids">online help</a> depending on the age of your child.</p>
<hr>
<p><em>For more information about vaccines and catch-up vaccination, call the <a href="https://www.health.gov.au/contacts/national-immunisation-information-line">National Immunisation Information Line</a> on 1800 671 811. For specific medical advice, see your health-care provider.</em></p><img src="https://counter.theconversation.com/content/199595/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Holly Seale is an investigator on research studies funded by NHMRC and has previously received funding for investigator driven research from NHMRC and NSW Ministry of Health, as well as from Sanofi Pasteur, Moderna and Seqirus.</span></em></p><p class="fine-print"><em><span>Abela Mahimbo has previously received funding from GSK for investigator driven research.</span></em></p><p class="fine-print"><em><span>Jane E Frawley does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Catch-up vaccinations are free. These hints and tips will help you get started.Holly Seale, Associate professor, UNSW SydneyAbela Mahimbo, Lecturer in Public Health, University of Technology SydneyJane E Frawley, NHMRC Research Fellow, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1969432023-02-22T19:04:16Z2023-02-22T19:04:16ZGastro or endometriosis? How your GP discusses uncertainty can harm your health<figure><img src="https://images.theconversation.com/files/507527/original/file-20230201-23-1odtda.jpg?ixlib=rb-1.1.0&rect=2%2C5%2C1914%2C1270&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/woman-suffering-from-a-stomach-pain-lying-down-on-couch-5938365/">Sora Shimazaki/Pexels</a></span></figcaption></figure><p>You wake with stomach pain that worsens during the day and decide to see your doctor. You describe your symptoms and your doctor examines you. Then the doctor says, “From what I hear, I think you could just have a stomach bug. Rest and come back in three days.”</p>
<p>This might be a less definitive answer than you’re after. But doctors can’t always be sure of a diagnosis straight away. As <a href="https://link.springer.com/article/10.1007/s11606-022-07768-y">my review</a> shows, doctors use various ways of communicating such uncertainty.</p>
<p>Sometimes there is a mismatch between what doctors say when they’re uncertain and how patients interpret what they say, which can have harmful consequences.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/missed-something-the-doctor-said-recording-your-appointments-gives-you-a-chance-to-go-back-112302">Missed something the doctor said? Recording your appointments gives you a chance to go back</a>
</strong>
</em>
</p>
<hr>
<h2>Why does uncertainty matter?</h2>
<p>Doctors <a href="https://link.springer.com/article/10.1007/s11606-017-4164-1">cannot always explain</a> what your health problem is or what caused it. Such diagnostic uncertainty is a normal and <a href="https://doi.org/10.1001/jama.2022.2141">ever-present part</a> of the processes leading to a diagnosis. For instance, doctors often have to rule out other possible diagnoses before settling on one that’s most likely.</p>
<p>While doctors ultimately get the diagnosis right <a href="http://dx.doi.org/10.1136/bmjqs-2012-001615">in 85-90%</a> of cases, diagnostic uncertainty can lead to diagnostic delays and is a huge contributor to harmful or even deadly misdiagnoses.</p>
<p>Every year, <a href="https://www.mja.com.au/system/files/issues/213_07/mja250771.pdf">an estimated</a> 21,000 people are seriously harmed and 2,000-4,000 people die in Australia because their diagnosis was delayed, missed or wrong. That could be because the wrong treatment was provided and caused harm, or the right treatment was not started or given after the condition had already considerably progressed. More than <a href="https://www.mja.com.au/system/files/issues/213_07/mja250771.pdf">80% of diagnostic errors</a> could have been prevented. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/502507/original/file-20221222-21-2rjrbe.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C1000%2C663&q=45&auto=format&w=1000&fit=clip"><img alt="Doctor with stethoscope around neck talking to patient" src="https://images.theconversation.com/files/502507/original/file-20221222-21-2rjrbe.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C1000%2C663&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/502507/original/file-20221222-21-2rjrbe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/502507/original/file-20221222-21-2rjrbe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/502507/original/file-20221222-21-2rjrbe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/502507/original/file-20221222-21-2rjrbe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/502507/original/file-20221222-21-2rjrbe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/502507/original/file-20221222-21-2rjrbe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Diagnostic uncertainty is a huge contributor to harmful or even deadly misdiagnoses.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/crop-close-woman-doctor-prescribe-treatment-1930965026">Shutterstock</a></span>
</figcaption>
</figure>
<p>Three medical conditions – infections, cancer and major vascular events (such as strokes or heart attacks) – are the so-called “<a href="https://doi.org/10.1515/dx-2019-0019">Big Three</a>” and cause devastating harm if misdiagnosed.</p>
<p>In my review, the top three symptoms – fever, chest pain and abdominal pain – were most often linked to diagnostic uncertainty. In other words, most of us will have had at least one of these very common symptoms and thus been at risk of uncertainty and misdiagnosis.</p>
<p>Some groups are less likely to be diagnosed correctly or without inappropriate delay than others, leading to <a href="https://doi.org/10.1001/jama.2022.7252">diagnostic inequities</a>. This may be the case for <a href="https://www.liebertpub.com/doi/10.1089/whr.2022.0052">women</a>, and other groups marginalised because of their <a href="https://onlinelibrary.wiley.com/doi/10.1111/acem.14142">race or ethnicity</a>, <a href="https://doi.org/10.1016/j.socscimed.2020.113609">sexual orientation or gender identity</a>, or <a href="https://doi.org/10.1001/jama.2022.7252">language proficiency</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-your-doctor-describes-your-medical-condition-can-encourage-you-to-say-yes-to-surgery-when-there-are-other-options-157958">How your doctor describes your medical condition can encourage you to say 'yes' to surgery when there are other options</a>
</strong>
</em>
</p>
<hr>
<h2>How often do you hear ‘I don’t know’?</h2>
<p>My research showed doctors often make diagnostic uncertainty clear to patients by using explicit phrases such as: “I don’t know.”</p>
<p>But doctors can also keep quiet about any uncertainty or signal they’re uncertain in more subtle ways.</p>
<p>When doctors believe patients prefer clear answers, they may only share the most likely diagnosis. They say: “It’s a stomach bug” but leave out, “it could also be constipation, appendicitis or endometriosis”. </p>
<p>Patients leave thinking the doctor is confident about the (potentially correct or incorrect) diagnosis, and remain uninformed about possible other causes. </p>
<p>This can be especially frustrating for patients with chronic symptoms, where such knowledge gaps can lead to lengthy diagnostic delays, as reported for <a href="https://doi.org/10.1016/j.ajog.2018.12.039">endometriosis</a>.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1064608335217942528"}"></div></p>
<p>Subtle ways of communicating uncertainty include hedging with certain words (could, maybe) or using introductory phrases (my guess, I think). Other implicit ways are consulting a colleague or the Internet, or making follow-up appointments.</p>
<p>If patients hear “I think this could be a stomach bug” they may think there’s some uncertainty. But when they hear “come back in three days” the uncertainty may not be so obvious.</p>
<p>Sharing uncertainty implicitly (rather than more directly), can leave patients unaware of new symptoms signalling a dangerous change in their condition.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/1-in-10-women-are-affected-by-endometriosis-so-why-does-it-take-so-long-to-diagnose-141803">1 in 10 women are affected by endometriosis. So why does it take so long to diagnose?</a>
</strong>
</em>
</p>
<hr>
<h2>What can you do about it?</h2>
<p><strong>1. Ask about uncertainty</strong></p>
<p>Ask your doctor to share any <a href="http://dx.doi.org/10.1515/dx-2021-0086">uncertainty and other diagnostic reasoning</a>. Ask about alternative diagnoses they’re considering. If you’re armed with such knowledge, you can better engage in your care, for example asking for a review when your symptoms worsen.</p>
<p><strong>2. Manage expectations together</strong></p>
<p>Making a diagnosis can be an evolving process rather than a single event. So ask your doctor to outline the diagnostic process to help manage any <a href="http://dx.doi.org/10.1136/ebm.14.3.66">mismatched expectations</a> about how long it might take, or what might be involved, to reach a diagnosis. Some conditions need time for symptoms to evolve, or further tests to exclude or confirm.</p>
<p><strong>3. Book a long appointment</strong></p>
<p>When we feel sick, we might get anxious or find we experience heightened levels of fear and other emotions. When we hear our doctor isn’t certain about what’s causing our symptoms, we may get even more anxious or fearful.</p>
<p>In these cases, it can take time to discuss uncertainty and to learn about our options. So book a long appointment to give your doctor enough time to explain and for you to ask questions. If you feel you’d like some support, you can ask a close friend or family member to attend the appointment with you and to take notes for you.</p>
<hr>
<p><em>I acknowledge the contribution of patient advocate Jen Morris and GP Marisa Magiros to this article. The systematic review mentioned was co-authored by Maria Dahm, William Cattanach, Maureen Williams, Jocelyne Basseal, Kelly Gleason and Carmel Crock</em>.</p><img src="https://counter.theconversation.com/content/196943/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maria R. Dahm receives funding from the Australian Research Council and the Society to Improve Diagnosis in Medicine. She is affiliated with the Australian New Zealand affiliate of the Society to Improve Diagnosis in Medicine. </span></em></p>Doctors don’t always tell you they’re unsure what’s behind common symptoms, such as a stomach ache. And that can have serious effects.Maria R. Dahm, ARC DECRA and Senior Research Fellow in Health Communication, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1984902023-02-05T12:54:18Z2023-02-05T12:54:18ZWhy is Canada snubbing internationally trained doctors during a health-care crisis?<figure><img src="https://images.theconversation.com/files/507489/original/file-20230201-26-8p3bpc.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6000%2C3628&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Canada has a shortage of doctors. That's why making it difficult for internationally trained doctors to practise here is so mystifying.</span> <span class="attribution"><span class="source">(Francisco Venancio, Unsplash)</span></span></figcaption></figure><p>Internationally trained doctors are being sidelined in Canada while <a href="https://www.ctvnews.ca/canada/6m-canadians-don-t-have-a-family-doctor-a-third-of-them-have-been-looking-for-over-a-year-report-1.6059581">six million Canadians</a> do not have a family doctor.</p>
<p>Internationally trained physicians, commonly known as international medical graduates, are medical professionals who completed their education outside of Canada or the United States. They are a diverse group of practitioners trained in various specialties. </p>
<p><a href="https://fammedarchives.blob.core.windows.net/imagesandpdfs/pdfs/FamilyMedicineVol41Issue3Klein197.pdf">Many move to Canada</a> for a better quality of life, training opportunities and political and economic security. Historically, most have migrated through the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4369608/#b3-0610205">Skilled Worker Express Entry Program</a>, which favours their extensive educational backgrounds. Nonetheless, they face multiple obstacles throughout the licensing process.</p>
<p>In October 2021, a community research team from Simon Fraser University, supported by an advisory committee, <a href="https://radiussfu.com/programs/labs-ventures/refugee-newcomer-livelihood/">led research on Canada’s exclusionary medical licensing policies.</a> </p>
<p>The project emerged from <a href="https://www.facebook.com/Trained-To-Save-Lives-101032234901108/">Trained To Save Lives</a>, a social media campaign about the role of internationally educated health-care professionals in British Columbia’s COVID-19 response.</p>
<p>We conducted interviews with 11 internationally trained doctors in B.C. While this study was conducted in B.C., the findings highlight licensing barriers for internationally trained doctors across Canada. </p>
<h2>Eight steps</h2>
<p>The path to being licensed in Canada is complex, especially since each province has its <a href="https://www.ctvnews.ca/health/calls-grow-to-streamline-licensing-for-doctors-as-health-care-systems-struggle-1.6071471">own licensing system</a>. In B.C., the requirements include:</p>
<ol>
<li><p>Internationally trained physicians must have a medical degree from an accredited school from the <a href="https://www.wdoms.org/">World Directory of Medical Schools.</a></p></li>
<li><p>They must provide language proficiency certification if the language of their obtained medical degree is not English and the provision of care is not undertaken in English.</p></li>
<li><p>They must pass the <a href="https://mcc.ca/examinations/mccqe-part-i/">Medical Council of Canada Qualifying Examination Part 1</a> and the <a href="https://mcc.ca/examinations/nac-overview/">National Assessment Collaboration Objective Structural Clinical Examination</a>. </p></li>
<li><p>They must apply for a <a href="https://imgbc.med.ubc.ca/clinical-assessment/">Clinical Assessment Program</a>.</p></li>
<li><p>They then must complete a residency or <a href="https://mcc.ca/assessments/practice-ready-assessment/">Practice Ready Assessment.</a></p></li>
<li><p>When applying for residency, they are required to sign a <a href="https://practiceinbc.ca/practice-in-bc/img-au-irl-uk-usa-residency-ca/return-of-service">Return of Service contract.</a></p></li>
<li><p>They must obtain a provincial licence. In B.C., these are granted by the College of Physicians and Surgeons of British Columbia.</p></li>
<li><p>Finally, they must go through a certification process involving national certification exams administered by the College of Physicians and Surgeons for family physicians or the Royal College of Physicians and Surgeons of Canada for specialists.</p></li>
</ol>
<h2>Licensing barriers</h2>
<p>From our interviews, we identified several barriers. The National Assessment Collaboration Objective Structural Clinical Examination, required for international medical graduates applying for Canadian post-graduate training, was noted as a key obstacle. </p>
<p>While graduates of Canadian and American medical schools do not need to complete this exam, internationally trained doctors must pay significant fees to undertake the assessment, which has few offerings annually. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/507892/original/file-20230202-5782-vp3d9u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="a doctor looks into a patient's eye with an instrument" src="https://images.theconversation.com/files/507892/original/file-20230202-5782-vp3d9u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/507892/original/file-20230202-5782-vp3d9u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/507892/original/file-20230202-5782-vp3d9u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/507892/original/file-20230202-5782-vp3d9u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/507892/original/file-20230202-5782-vp3d9u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/507892/original/file-20230202-5782-vp3d9u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/507892/original/file-20230202-5782-vp3d9u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Internationally trained doctors face requirements to get licensed in Canada that Canadian and American doctors don’t.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>Several endured long wait times and encountered problems with settlement workers regarding their career prospects. They were told their education “meant nothing” in Canada.</p>
<p>Internationally trained physicians highlighted a lack of transparency, including unclear information about licensing. Although they expected being relicensed would be arduous, they were unprepared for the difficulties they faced.</p>
<p>Their experiences contradicted the federal <a href="https://www.canada.ca/en/immigration-refugees-citizenship/campaigns/immigration-matters/system.html">immigration department’s call for skilled workers</a>. Instead, many were pushed into <a href="https://doi.org/10.2147/RMHP.S60708">low-paying, precarious jobs</a> that don’t match their education or experience.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/gig-platforms-help-immigrant-care-workers-find-jobs-but-they-are-only-a-temporary-solution-194791">Gig platforms help immigrant care workers find jobs, but they are only a temporary solution</a>
</strong>
</em>
</p>
<hr>
<h2>Scant residency spots</h2>
<p>One of the most profound barriers that internationally trained doctors have <a href="https://vancouversun.com/health/local-health/bc-has-a-doctor-shortage-and-yet-there-are-100s-of-physicians-here-who-arent-allowed-to-practise-medicine">lobbied against</a> is the limited number of residency positions available for them. </p>
<p>Residency is <a href="https://imgbc.med.ubc.ca/">post-graduate training</a> required for licensing. The Canadian Resident Matching Service, the organization responsible for matching applicants with residency programs, <a href="https://doi.org/10.36834/cmej.71790">separates positions into two streams</a>: Canadian medical graduates, and international medical graduates. </p>
<p>When applying, international medical graduates are permitted to compete for just <a href="https://www.canadianonpaper.com/">10 per cent of positions</a> and are restricted to a handful of under-serviced specialties, like family medicine.</p>
<p>Another systemic barrier is the aforementioned Return of Service contracts. Under these contracts, internationally trained doctors who secure residency positions must work in an <a href="https://canadianonpaper.com/wp-content/uploads/2021/06/Fact-Sheet.pdf">under-served community</a> for two to five years (excluding Alberta and Québec).</p>
<p>Just as Canadian medical school graduates do not have to complete the National Assessment Collaboration Objective Structural Clinical Examination, nor are they required to work in under-served communities for years. </p>
<p>Collectively, these barriers negatively impact the mental health and well-being of internationally trained doctors.</p>
<figure class="align-center ">
<img alt="A doctor from the shoulders down looks at a phone and has a stethscope around his neck." src="https://images.theconversation.com/files/507492/original/file-20230201-14-qtbg4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/507492/original/file-20230201-14-qtbg4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/507492/original/file-20230201-14-qtbg4i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/507492/original/file-20230201-14-qtbg4i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/507492/original/file-20230201-14-qtbg4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/507492/original/file-20230201-14-qtbg4i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/507492/original/file-20230201-14-qtbg4i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The many obstacles placed in the path of internationally trained and highly qualified doctors can cause mental health issues.</span>
<span class="attribution"><span class="source">(Unsplash)</span></span>
</figcaption>
</figure>
<h2>Changes ahead</h2>
<p>Some provinces have introduced initiatives to enable internationally trained doctors to practice. The College of Physicians and Surgeons of Alberta <a href="https://www.cbc.ca/news/canada/edmonton/alberta-now-offering-accelerated-licensing-for-internationally-trained-doctors-specialists-1.6717322">announced a pilot project to waive some requirements</a>, but only for doctors from <a href="https://cpsa.ca/physicians/registration/apply-for-registration/additional-route-to-registration-imgs/">approved jurisdictions</a>, like the United States. </p>
<p>The B.C. Practice Ready Assessment program will also increase from 32 to 96 seats to provide internationally educated family doctors with post-graduate training an “<a href="https://www.prabc.ca/">alternate pathway to licensure</a>.” </p>
<p>Although these are important steps forward, they don’t address all the systemic barriers to licensing. They do not allow these qualified physicians to use their expertise to support <a href="https://www.cbc.ca/news/canada/british-columbia/bc-covid19-hospitalizations-jan-19-1.6320559">a strained health-care system</a>. </p>
<p>The federal government recently launched <a href="https://ca.style.yahoo.com/government-canada-launches-call-proposals-160400241.html?guccounter=1&guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAACUcUO9MXEhLKD89iIXP3CtV_dM2La4p6H5zpFbkA_M-rZKGndUgimEPrt44Ixw8b9Ry3gWfgYvFr7fXzhcXw1kWevgoiSi225qsKiRyf7u2wv2skzfQV0gy-0olkexFnpWdjHcnTNDrBUXtwK1hJH3DxqpL6Hyo-hVbkJH4eCO8">a call for proposals</a> aimed at addressing Canada’s labour shortage by allowing internationally educated professionals to work in the Canadian health-care system.</p>
<p>Meaningful engagement with internationally trained physicians is also required to integrate them into the health-care workforce. We propose:</p>
<ol>
<li><p>Providing transparent and clear information about licensing requirements prior to migration. </p></li>
<li><p>Prioritizing mental health supports upon arrival and during the licensing process.</p></li>
<li><p>Increasing the number of residency positions and medical specialties for internationally trained physicians.</p></li>
</ol><img src="https://counter.theconversation.com/content/198490/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The research team has no funding sources or affiliations to declare.</span></em></p><p class="fine-print"><em><span>Evelyn Encalada Grez and Paola Ardiles do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Canada is sidelining qualified doctors while many Canadians struggle to find health care. Here’s what we can and must do better for internationally trained physicians.Simran Purewal, Research Associate, Health Sciences, Simon Fraser UniversityEvelyn Encalada Grez, Assistant Professor, Labour Studies, Simon Fraser UniversityPaola Ardiles, Senior Lecturer, Health Sciences, Simon Fraser UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1986992023-02-03T12:23:35Z2023-02-03T12:23:35ZGP numbers continue to fall but the UK isn’t unique in losing family doctors<p>The 2019 Conservative manifesto promised to increase the UK’s GP numbers by <a href="https://www.conservatives.com/our-plan/conservative-party-manifesto-2019">6,000 by 2024</a>. That target will clearly not be met. In fact, the proportion of GPs working full time in England has fallen compared with last year, according to the latest figures from <a href="https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services/31-december-2022#">NHS Digital</a>.</p>
<p>There were 26,706 permanent qualified GPs working in England in December 2022, down from 27,064 in December 2021. And if projections from the <a href="https://www.health.org.uk/news-and-comment/charts-and-infographics/the-gp-shortfall-in-numbers">Health Foundation</a> prove to be accurate, the shortfall is set to increase to around 8,800 GPs by 2030-31, equivalent to one in four posts being vacant. But is the UK unique among wealthy nations in suffering from a crisis in primary care?</p>
<p>It appears not. <a href="https://www.cornerstonehealth.com.au/latest-news/general-practitioner-workforce-report-2022">Australia has a GP shortage</a> that is predicted to grow to more than 11,000 by 2032, with the demand for GP services increasing by 38.5% in that time. Likewise, <a href="https://www.cfpc.ca/en/position-statement-on-workforce-supply-for-family-medicine-in-canada">Canada</a> and <a href="https://www.rnzcgp.org.nz/gpdocs/new-website/publications/2021-GP-future-workforce-report-FINAL.pdf">New Zealand</a> have similar GP workforce problems. </p>
<p>In New Zealand, half of its GP workforce intends to retire in the next decade. While Canada has seen a modest <a href="https://www.cihi.ca/en/physicians">1.2% increase</a> in the number of family doctors, the demand for primary care services continues to outpace the supply of doctors.</p>
<p>In the UK, a quarter of all doctors are GPs, whereas it is one in three in Australia, and nearly one in two in Canada. Extrapolating from <a href="https://www.who.int/data/gho/data/indicators/indicator-details/GHO/medical-doctors-(per-10-000-population)">World Health Organization data</a>, Australia and Canada have roughly similar numbers of GPs per head of population (12 and 11 per 10,000 population respectively), but the UK lags considerably behind (less than eight per 10,000 population). </p>
<p>However, <a href="https://www.oecd-ilibrary.org/sites/aa9168f1-en/index.html?itemId=/content/component/aa9168f1-en#:%7E:text=GPs%20%28family%20doctors%29%20represented%20less%20than%20one-quarter%20%2823%25%29,to%20variation%20in%20the%20ways%20doctors%20are%20categorised.">international comparisons are difficult</a> because how GPs are defined and what they do differs from country to country. </p>
<p>In the UK, the nature of general practice has changed considerably in the past two decades. British GPs deal with more than minor ailments. </p>
<p>In addition to triaging referrals to hospital specialists and providing health screening and vaccination services, they also manage patients’ chronic diseases (such as diabetes), which were previously handled by hospital specialists. They also play a key role in coordinating healthcare for patients in long-stay care facilities, such as nursing and residential homes.</p>
<p>British GPs are also having to care for more patients with complex health conditions because the population is ageing and many people have more than one chronic condition – known as “multi-morbidity”. One English study estimated that over a quarter of patients have <a href="https://bjgp.org/content/68/669/e245.short">two or more long-term conditions</a>. </p>
<p>Having multi-morbidity is associated with increased health service use. These patients account for more than half of all GP consultations and hospital admissions. Multi-morbidity is also much more common in older populations. </p>
<p>A large Scottish study found that <a href="https://www.sciencedirect.com/science/article/pii/S0140673612602402">more than 80%</a> of patients over the age of 85 years had multi-morbidity, and, on average, they had more than three long-term conditions. </p>
<p>It is unsurprising that the demand for GP services has gone up over the years in the UK, and will continue to do so, as the proportion of the population that is elderly increases. The UK Office for National Statistics estimates that the proportion of people aged 85 years and over will <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/bulletins/nationalpopulationprojections/2018based">almost double over the next 25 years</a>. </p>
<p>With falling GP numbers, the pressure felt by GP services will continue to increase as demand outstrips supply.</p>
<p><strong>The number of people of pensionable age is projected to grow the most</strong></p>
<figure class="align-center ">
<img alt="Graph showing the number of people of pensionable age is projected to grow the most" src="https://images.theconversation.com/files/507599/original/file-20230201-9697-rsj2qx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/507599/original/file-20230201-9697-rsj2qx.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=414&fit=crop&dpr=1 600w, https://images.theconversation.com/files/507599/original/file-20230201-9697-rsj2qx.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=414&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/507599/original/file-20230201-9697-rsj2qx.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=414&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/507599/original/file-20230201-9697-rsj2qx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=520&fit=crop&dpr=1 754w, https://images.theconversation.com/files/507599/original/file-20230201-9697-rsj2qx.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=520&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/507599/original/file-20230201-9697-rsj2qx.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=520&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/bulletins/nationalpopulationprojections/2018based">Office for National Statistics</a></span>
</figcaption>
</figure>
<h2>Reasons for leaving</h2>
<p>So why do so many GPs leave the profession? One consequence of the high work pressures and long hours is burnout. This phenomenon is not unique to the UK and has been reported worldwide, with some estimates as high as <a href="https://bjgp.org/content/bjgp/72/718/e316.full.pdf">one in three GPs suffering burnout</a>. The pandemic has also had an impact on GP burnout worldwide.</p>
<p>Burnout and job dissatisfaction have been identified as <a href="https://www.nuffieldtrust.org.uk/resource/the-long-goodbye-exploring-rates-of-staff-leaving-the-nhs-and-social-care">key reasons for British GPs leaving the NHS</a>. In one survey, three-quarters of British GPs reported their workload to be <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60470-6/fulltext">unmanageable or unsustainable</a>.</p>
<p>Another UK study conducted in 2016-17 suggested that <a href="https://bjgp.org/content/69/684/e507.full">more than 70% of GPs reported severe exhaustion</a>. Burnout was associated with spending more hours on administrative tasks, seeing more patients daily, and feeling less supported.</p>
<p>Australia and New Zealand have for some years been attractive options for British-trained GPs for numerous reasons. The current NHS climate and workload may be <a href="https://www.sciencedirect.com/science/article/pii/S0168851019302234?casa_token=0MThdnf4K08AAAAA:kUJBJPOnEQ_ZYbE4OscxKAlZetDgjWvM9PhFGor48Z-MSlK2Xw_mpmxPPbK41umpvoVSqlpHnFUe">driving some doctors away from the UK</a>. </p>
<p><a href="https://journals.sagepub.com/doi/pdf/10.1258/jrsm.2011.110146">One survey</a> of UK-trained doctors in New Zealand found that 70% had relocated for a better lifestyle, due to poorer job satisfaction in the UK and disillusionment with the NHS. Doctors in New Zealand also had comparatively more leisure time than NHS doctors.</p>
<p>So what can be done? </p>
<h2>How to keep GPs</h2>
<p>To increase the number of GPs in the UK, sustained government funding and a long-term GP workforce strategy and plan are essential. To fix its recruitment and retention crisis, the UK needs to address the <a href="https://bjgp.org/content/bjgp/67/657/e227.full.pdf">unhealthy work climate</a> for GPs by improving support, reducing their administrative workloads, and tackling their patient workload intensity and volume, as well as long hours. </p>
<p>England is also trying some innovative schemes such as the “additional roles reimbursement scheme”, where networks of GPs are able to recruit additional staff such as physiotherapists, paramedics and pharmacists to augment their clinical teams and enable some tasks to be shifted from GPs. </p>
<p>However, the workforce for these roles is also in short supply, and some will need time and GP supervision to learn the skills needed to operate effectively in the community. </p>
<p>Trying to recruit more GPs or these allied health professionals from abroad is unlikely to succeed given the global shortage of both these groups of professionals. </p>
<p>Contrary to public myth, GPs generally also wanted more direct contact with their patients and valued the continuity of care – the loss of which has been cited as a <a href="https://bjgp.org/content/66/643/e128.short">reason why GPs leave general practice early</a>. Public expectations will need to be managed, and negative media portrayals and criticisms of GPs are unlikely to help improve the worsening primary care situation.</p><img src="https://counter.theconversation.com/content/198699/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Lee has previously received research funding from the National Institute for Health Research. He is a member of the UK Faculty of Public Health and the Royal Society for Public Health. He was previously a GP in Sheffield.</span></em></p>How can the UK hold on to its GPs? Here are some solutions.Andrew Lee, Professor of Public Health, University of SheffieldLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1962432022-12-16T14:25:40Z2022-12-16T14:25:40ZGPs don’t give useful weight-loss advice – new study<figure><img src="https://images.theconversation.com/files/501319/original/file-20221215-15-z95ckr.jpg?ixlib=rb-1.1.0&rect=7%2C0%2C4977%2C3303&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Have you tried eating less and moving more?</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-female-doctor-senior-male-patient-280364663">Monkey Business Images/Shutterstock</a></span></figcaption></figure><p>The advice general practitioners give to patients with obesity in the UK was found to be “highly varied, superficial and often lacked an apparent evidence base”, according to a <a href="https://academic.oup.com/fampra/advance-article/doi/10.1093/fampra/cmac137/6849537?login=true">new study</a> from the University of Oxford.</p>
<p>GPs in the UK are in a trusted position as guides and managers of health in their communities. Expectations of them are often high: they are the personal advisers, taking stock of their patients’ physical and mental health, and delivering tailored advice and treatments.</p>
<p>A formidable test of general practice in the last 50 years has been the rise in obesity. Not an illness in itself and not a new phenomenon, but a significant potential threat to health. </p>
<p>It is widely known that corpulence does not yield easily to diet or exercise. In 1865, William Banting, an English undertaker and coffin maker, <a href="https://www.gutenberg.org/cache/epub/57545/pg57545-images.html">published a combination of these two strategies</a> to help reduce the stoutness of English Victorians. William Osler, a professor of medicine at Oxford University, in 1892 elaborated further on ideal foods and physical activity in <a href="https://en.wikipedia.org/wiki/The_Principles_and_Practice_of_Medicine">The Principles and Practice of Medicine</a>. Both pointed out that these approaches worked slowly, requiring considerable motivation to be effective.</p>
<p>Globally, the number of obese children and adults <a href="https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight">remains very high</a>, and progress in prevention and treatment has been slow. Many separate approaches are needed to optimise our diets, our food supplies and ourselves. </p>
<p>Current guidelines in the UK encourage GPs to talk to obese patients about their weight and discuss ways to lose weight. <a href="https://www.sciencedirect.com/science/article/pii/S0140673616318931">Evidence shows</a> that even brief conversations can lead to weight loss. </p>
<p>In this latest study, published in the journal Family Practice, the researchers analysed 159 audio recordings of consultations between GPs and obese patients in which doctors gave brief (up to 30 seconds) weight-loss advice. The recordings were made between 2013 and 2014 across 137 GP surgeries.</p>
<p>Word analysis of these conversations provided surprising results. If the patients had followed the advice given in most of the consultations, they would not have lost weight.</p>
<p>The most frequent advice was essentially “eat less and do more”. Only 30 patients were given personalised advice, that is, where GPs “took into account patients’ capacity to follow the advice, such as a patient’s limited physical mobility and the implications on this for exercise”. </p>
<p>In half the interviews (78 instances), GPs also advise patients to access further support, such as a follow-up appointment or referral to a gym. </p>
<p>The advice provided by GPs in the recordings was not always accurate. Many elements of advice included, for instance, the idea that small behavioural changes could result in a large loss of weight. Banting showed this to be a myth back in the early 19th century. </p>
<figure class="align-center ">
<img alt="Woman doing sit ups in a gym." src="https://images.theconversation.com/files/501515/original/file-20221216-27-q0pir7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/501515/original/file-20221216-27-q0pir7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/501515/original/file-20221216-27-q0pir7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/501515/original/file-20221216-27-q0pir7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/501515/original/file-20221216-27-q0pir7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/501515/original/file-20221216-27-q0pir7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/501515/original/file-20221216-27-q0pir7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">GPs recommended gym prescriptions in just 4 consultations.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/fat-woman-dieting-fitness-portrait-obese-1893029500">Oleggg/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Things have improved since 2014</h2>
<p>In 2014, few GPs were well-trained in this area of counselling. The more specialised areas of motivational counselling and setting realistic weight-loss goals for patients were also difficult. So although patients would prefer to speak to a GP about their weight, those GPs felt underqualified to do so. </p>
<p>Developing and improving advice given to patients since 2014 has featured increasingly in primary care education and guidelines from the UK’s National Institute for Health and Care Excellence. </p>
<p>New systems are being deployed, such as the use of social prescribing that permit a GP to recommend various “community referrals” such as prescribing a gym membership. This shared responsibility between those with greater expertise is powerful, reduces stigma and encourages independence in those who are overweight or obese. </p>
<p>These approaches have been reinforced by Public Health England’s campaign to help people make healthier choices - this includes the free <a href="https://www.nhs.uk/better-health/lose-weight/">NHS Weight Loss Plan</a> app. </p>
<p>Advice concerning health and weight is particularly valuable – and <a href="https://www.sciencedirect.com/science/article/pii/S0140673616318931">it works</a>. Improving it can only support the very difficult job of tackling obesity. This long, slow journey requires all of us to be participants.</p><img src="https://counter.theconversation.com/content/196243/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Colin Michie does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>GPs’ advice on weight loss for people with obesity is often ‘superficial’, but things have improved in recent years.Colin Michie, Deputy Lead, School of Medicine, University of Central LancashireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1871582022-07-19T02:34:41Z2022-07-19T02:34:41Z6 steps to making a COVID plan, before you get sick<figure><img src="https://images.theconversation.com/files/474562/original/file-20220718-24-wxze37.jpg?ixlib=rb-1.1.0&rect=50%2C80%2C6659%2C3691&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/female-doctor-medical-facial-mask-600w-1880874019.jpg">Shutterstock</a></span></figcaption></figure><p>With COVID cases, hospital admissions and deaths <a href="https://www.theguardian.com/australia-news/datablog/ng-interactive/2022/jul/15/covid-19-cases-australia-today-vaccine-data-tracker-booster-4th-dose-fourth-nsw-qld-vic-victoria-hospitalisations-coronavirus-variant-tracking-stats-live-update-by-state-how-many-people-vaccination-total-new-case-numbers-statistics-deaths-per-day-death-toll">resurging</a>, every Australian needs to know what they can do to reduce their risk of becoming seriously unwell.</p>
<p>Last week, Minister for Health and Aged Care Mark Butler advised Australians who are at higher risk of becoming seriously unwell with COVID to <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/millions-of-australians-to-gain-access-to-covid-treatments">consult their GPs</a> and make a plan for what they will do if they are infected. </p>
<p>But what should you ask your GP? And what information can you provide them with to ensure you have a COVID plan in place and can access the right treatment when you need it?</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australia-is-heading-for-its-third-omicron-wave-heres-what-to-expect-from-ba-4-and-ba-5-185598">Australia is heading for its third Omicron wave. Here's what to expect from BA.4 and BA.5</a>
</strong>
</em>
</p>
<hr>
<h2>Antivirals for mild cases</h2>
<p>Two oral COVID treatments are available on the Pharmaceutical Benefits Scheme for use at home by people who have been diagnosed with mild COVID illness and who are at elevated risk of becoming seriously ill: <a href="https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/new-covid-19-oral-treatment-on-pbs">Lagevrio and Paxlovid</a>. </p>
<p>To reduce the risk of progression to severe disease and hospitalisation, these treatments must be started as soon as possible, within <a href="https://www.tga.gov.au/media-release/tga-provisionally-approves-two-oral-covid-19-treatments-molnupiravir-lagevrio-and-nirmatrelvir-ritonavir-paxlovid">five days</a> of when symptoms start. </p>
<p>Nirmatrelvir plus ritonavir (Paxlovid) is the <a href="https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/conditions/infectious+diseases/covid-19/health+professionals/monoclonal+antibody+infusion+application+for+covid-19+positive+patients">more effective</a> of these two treatments but it can have complex interactions with many <a href="https://www.covid19-druginteractions.org/checker">common medicines</a>. </p>
<p>Working out whether a person qualifies for these treatments, whether the treatments are safe for them and giving appropriate advice often takes more than 20 minutes in a consultation with your GP. </p>
<p>You can reduce the stress on yourself and on your GP and their practice by discussing these questions while you are well and before any COVID infection is suspected or detected.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/474561/original/file-20220718-20-ldhnqz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="older man on phone" src="https://images.theconversation.com/files/474561/original/file-20220718-20-ldhnqz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/474561/original/file-20220718-20-ldhnqz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/474561/original/file-20220718-20-ldhnqz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/474561/original/file-20220718-20-ldhnqz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/474561/original/file-20220718-20-ldhnqz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/474561/original/file-20220718-20-ldhnqz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/474561/original/file-20220718-20-ldhnqz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">If you have a regular GP, go see them and check your eligibility for COVID antivirals.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/senior-businessman-talking-on-mobile-600w-1438971779.jpg">Shutterstock</a></span>
</figcaption>
</figure>
<h2>A 6-step plan to stay as well as possible</h2>
<h2>1. Find a GP</h2>
<p>If you don’t yet have a usual GP or general practice, <a href="https://www.healthdirect.gov.au/australian-health-services">choose one now</a> and ask for an appointment of at least 30 minutes. The purpose of this consultation is for the GP to gain an understanding of your state of health, and so you can make a plan together for what you and the GP will do if you are infected with COVID. </p>
<p>Medicare benefits are payable in these circumstances only for in-person consultations – but you should attend the general practice only if you are well and not a close contact of someone with COVID. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/people-attending-gps-arent-getting-all-the-preventive-health-care-they-need-heres-what-could-help-181709">People attending GPs aren't getting all the preventive health care they need. Here's what could help</a>
</strong>
</em>
</p>
<hr>
<h2>2. Check your eligibility</h2>
<p>If you already have a usual GP or practice, make an appointment with them and check whether you are eligible for PBS-subsidised oral antiviral treatment. Should you be diagnosed with COVID infection, it is important to be prepared as treatment must start as soon as possible.</p>
<p>The <a href="https://www.health.gov.au/health-alerts/covid-19/treatments/eligibility">eligibility criteria</a> for subsidised antiviral COVID treatments have recently been expanded. Now people aged 70 years and older can access the treatments, as can people over 50 with two or more risk factors, Aboriginal or Torres Strait Islander people over 30 with two or more risk factors, and people with compromised immunity who are over 18.</p>
<p>If you meet the criteria, or you are not sure whether you are in a higher risk group, ask for an appointment with your GP to check eligibility and to make a plan. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/covid-drugs-in-australia-whats-available-and-how-to-get-them-186907">COVID drugs in Australia: what's available and how to get them</a>
</strong>
</em>
</p>
<hr>
<h2>3. Get all the COVID vaccinations you’re due</h2>
<p>Have all doses of COVID vaccine recommended for your age and health status, as soon as you are eligible for each dose. The <a href="https://www.health.gov.au/initiatives-and-programs/covid-19-vaccines">currently recommended</a> numbers of doses are: two doses for children aged 5 to 15 years; three doses for adolescents and adults aged 16 to 29 (additional doses are recommended for children and adolescents with disabilities or chronic conditions); three doses for adults aged 30 to 49 with an optional fourth dose; and four doses for adults over 50.</p>
<p>ATAGI <a href="https://theconversation.com/covid-vaccination-recommendations-evolve-over-time-who-is-due-for-which-dose-now-181779">recommends</a> vaccination to prevent serious illness and death from COVID.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/covid-vaccination-recommendations-evolve-over-time-who-is-due-for-which-dose-now-181779">COVID vaccination recommendations evolve over time. Who is due for which dose now?</a>
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</em>
</p>
<hr>
<h2>4. Get your flu vaccine too</h2>
<p>Have this year’s influenza vaccine now if you have not already received it. The influenza vaccine is recommended for everybody over six months old and is available from GPs and pharmacies. </p>
<p>The influenza vaccine can be <a href="https://theconversation.com/when-can-i-get-my-next-covid-booster-or-fourth-dose-what-if-ive-recently-had-covid-can-i-get-my-flu-shot-at-the-same-time-186830">given at the same time</a> as a COVID vaccine. Some GPs and pharmacies charge a consultation or service fee for administering the vaccine. </p>
<p>If you aren’t sure how many doses of COVID vaccine you have had or when you received them, or whether you have had this year’s influenza vaccine, you can check in your <a href="https://www.myhealthrecord.gov.au/for-you-your-family/before-you-register">My Health Record</a> or you can view your COVID vaccinations though your <a href="https://www.servicesaustralia.gov.au/how-to-get-proof-your-covid-19-vaccinations?context=60091">MyGov</a> account that you have linked to Medicare. Your GP can also check for you during a consultation.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/which-flu-shot-should-i-choose-and-what-are-cell-based-and-adjuvanted-vaccines-184325">Which flu shot should I choose? And what are cell-based and 'adjuvanted' vaccines?</a>
</strong>
</em>
</p>
<hr>
<h2>5. Mask up</h2>
<p>Wear an effective mask (preferably not a cloth one) everywhere you can’t physically distance yourself from other people. This is especially important in indoor crowded places, as well as in places where masks are required such as health and aged care facilities. Continue with hand hygiene too.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/time-to-upgrade-from-cloth-and-surgical-masks-to-respirators-your-questions-answered-174877">Time to upgrade from cloth and surgical masks to respirators? Your questions answered</a>
</strong>
</em>
</p>
<hr>
<h2>6. Check your medicine cabinet</h2>
<p>Make a list of the medicines (including supplements and over the counter drugs) that you’re taking and how often you take them. </p>
<p>If you are able to, check online whether you are using any medicines that are known to interact with COVID drugs. Some people prescribed Paxlovid will have to stop or reduce the dose of one or more of their usual medicines while using it. Others might not be able to use Paxlovid safely, in which case one of the other treatment options can be considered. </p>
<p>The <a href="https://www.covid19-druginteractions.org/checker">online tool</a> can generate and save a report with any known interactions between Paxlovid and your usual medicines. Then you can email or show that list to your GP once you have made an appointment for a consultation. Your GP will also be able to check potential drug interactions for you during your pre-COVID appointment.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/im-at-home-with-covid-when-do-i-need-to-see-a-doctor-and-what-treatments-are-available-176884">I’m at home with COVID. When do I need to see a doctor? And what treatments are available?</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/187158/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Oliver Frank does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>If you do get COVID and you’re eligible for antiviral treatment, you’ll want to get them quickly. That’s why being prepared is a good idea.Oliver Frank, Senior Research Fellow, Discipline of General Practice, and Specialist General Practitioner, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1605322021-07-02T03:09:51Z2021-07-02T03:09:51ZBe kind: GP receptionists are taking the heat with every policy update during COVID, vaccines included<figure><img src="https://images.theconversation.com/files/400672/original/file-20210514-13-15pp9gi.jpg?ixlib=rb-1.1.0&rect=0%2C5%2C997%2C529&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/receptionist-woman-office-reception-wearing-face-1726918939">from www.shutterstock.com</a></span></figcaption></figure><p>Phones are ringing off the hook at <a href="https://www.ausdoc.com.au/news/chaos-reigns-gps-swamped-demand-astrazeneca-vax-under40s">GP clinics</a> <a href="https://www.annfammed.org/content/covid-19-collection-global-primary-care-during-covid-19">with people</a> desperate to know when and how they can be vaccinated against COVID-19. </p>
<p>Every time there is a change in recommendations or advice, medical receptions field calls from concerned people trying to book in to talk to a GP or to cancel bookings. This is on top of supporting patients and juggling the extra workload required to perform COVID-19 triage, screening and telehealth.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1409459128603275264"}"></div></p>
<p>GPs and practice nurses are considered <a href="https://www1.racgp.org.au/ajgp/coronavirus/australias-primary-care-covid19-response">central and front line</a> in Australia’s primary care COVID-19 response. However, GP receptionists are one step in front. </p>
<p>Their role has changed considerably during the pandemic, taking on functions and learning new skills no-one planned for. We must not forget them and the stressful work they do.</p>
<h2>All in a day’s work</h2>
<p>Medical receptionists are an integral part of <a href="https://www.racgp.org.au/download/Documents/Standards/RACGP-Standards-for-general-practices-5th-edition.pdf">general practice teams</a> and GP clinics would be challenged to exist without them. Doctors, nurses and other staff rely on medical receptionists to create a friendly, welcoming and well-organised front-of-clinic for patients. </p>
<p>Some people assume medical receptionists “just” answer phone calls, notify doctors when patients have arrived and make follow-up appointments. But this not only understates their true impact and influence on our health system, it does not acknowledge the challenges and pressures of their work.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-can-younger-australians-decide-about-the-astrazeneca-vaccine-a-gp-explains-163733">How can younger Australians decide about the AstraZeneca vaccine? A GP explains</a>
</strong>
</em>
</p>
<hr>
<p>Long before the pandemic, medical receptionists were <a href="https://www.semanticscholar.org/paper/Medical-receptionists-in-general-practice%3A-Who-a-Patterson-Mar/4b51152b3a994796f1c9dd8ceaa772e254ef5e6c">increasingly undertaking clinical duties</a>, performing tasks involving direct patient assessment, monitoring and therapy. </p>
<p>Medical receptionists were typically in this situation because of a lack of <a href="https://www.uow.edu.au/media/2020/research-finds-primary-health-care-nurses-losing-work-during-pandemic.php">financial support for practice nurses</a>. But, given receptionists are not trained health professionals and are continuously handling confidential information about patients, there’s the risk they may be held <a href="https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwjFmb62ocPxAhXESH0KHWKvDyMQFjAKegQIGRAD&url=https%3A%2F%2Fespace.library.uq.edu.au%2Fview%2FUQ%3A8923%2FRisk1.pdf&usg=AOvVaw07fkvpK9ipdDfyH6ig8Wve">legally liable</a> for making a mistake. </p>
<h2>Then came the pandemic</h2>
<p>The role of medical receptionists has profoundly changed due to the pandemic, though they have not being included in pandemic planning. </p>
<p>The Royal Australian College of General Practitioners has said <a href="https://www.racgp.org.au/health-of-the-nation/chapter-2-general-practice-access/2-2-gp-workforce">many receptionists</a> have been providing health and safety advice to patients and the wider community.</p>
<p>They are routinely asking patients questions about their travel history and symptoms, and monitoring body temperature to assess the risk of a patient being infected with COVID-19, despite not being trained to make clinical decisions.</p>
<p>They are increasingly performing <a href="https://www1.racgp.org.au/newsgp/clinical/should-suspected-coronavirus-patients-present-to-g">basic triage</a> over the phone and at the front desk, essentially assessing “how sick” a patient is and how timely their care needs to be.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1377021338011901955"}"></div></p>
<p>Particularly during the pandemic, it is usually their decision whether a patient is granted a face-to-face appointment, seen in their car, placed in an isolation room for their consultation, or asked to go to the hospital instead. </p>
<p>Medical receptionists are also relied on for <a href="https://www1.racgp.org.au/newsgp/racgp/racgp-recognises-the-unheralded-heroes-of-covid-19">technical support</a> for telehealth and to train clinicians and patients to use it. </p>
<p>Deciding if a patient is suitable for telehealth alone requires a basic understanding of what the doctor might need. We wouldn’t expect any medically untrained person to make these decisions, yet we expect our receptionists to.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/view-from-the-hill-scott-morrisons-astrazeneca-hand-grenade-turns-into-cluster-bomb-163680">View from The Hill: Scott Morrison's AstraZeneca 'hand grenade' turns into cluster bomb</a>
</strong>
</em>
</p>
<hr>
<h2>No wonder it’s stressful</h2>
<p>Medical receptionists are rightly concerned about <a href="https://www.racgp.org.au/health-of-the-nation/chapter-2-general-practice-access/2-2-gp-workforce">contracting COVID-19</a> as they are so close to unwell patients in the waiting room.</p>
<p>Threats of violence from frightened patients are also <a href="https://www1.racgp.org.au/newsgp/professional/violence-towards-gps-and-staff-a-growing-problem-n">now a reality</a>. And when a patient has not been booked in correctly, or worse, when a patient enters a consultation room showing COVID-19 symptoms, they cop dissatisfaction from clinicians and patients alike.</p>
<figure class="align-center ">
<img alt="Woman looking stressed or scared wearing a mask" src="https://images.theconversation.com/files/409409/original/file-20210702-19-1q80ezo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/409409/original/file-20210702-19-1q80ezo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/409409/original/file-20210702-19-1q80ezo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/409409/original/file-20210702-19-1q80ezo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/409409/original/file-20210702-19-1q80ezo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/409409/original/file-20210702-19-1q80ezo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/409409/original/file-20210702-19-1q80ezo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Working as a medical receptionist in a pandemic can take its toll.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/receptionist-woman-wearing-covid-ffp2-face-1925465327">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>The <a href="https://medicalrepublic.com.au/emotional-rescue-patients/7049">emotional demand</a> on medical receptionists is also very high. Supporting clinical teams and their personal feelings and expressions is now part of the job, as well as advocating for, and empathising with patients.</p>
<p>They do all this for an average <a href="https://www.payscale.com/research/AU/Job=Medical_Receptionist/Hourly_Rate">A$23.96 an hour</a>, much less than administrative or secretary work outside the health-care sector. </p>
<h2>Training and support are critical</h2>
<p>There is no required qualification to become a medical receptionist. However, courses such as a Certificate III in Business Administration or Certificate IV in Health Administration are <a href="https://www.seek.com.au/career-advice/role/medical-receptionist">recommended</a>. Truthfully, no training exists to equip medical receptionists for the additional pressures of the coronavirus pandemic. </p>
<p>Informal tips are circulating about how practice owners can <a href="https://www.wolterskluwer.com/en/expert-insights/9-ways-to-fight-burnout-in-overworked-medical-staff">support staff to avoid burnout</a>, and also how medical receptionists can <a href="https://www.avant.org.au/news/the-subtle-art-of-good-triage-for-medical-receptionists/">enhance their clinical and triage work</a>. </p>
<p>Unfortunately, current tips and training do not address the fundamental problem of medical receptionists not being recognised, trained or paid accordingly for their growing clinical, management and administrative work. </p>
<h2>Get vaccinated, be kind</h2>
<p>GP clinics still play a vital role in getting Australians vaccinated and helping us emerge from the pandemic. That’s on top of their existing role.</p>
<p>Receptionists are at the front line of this pandemic, changing what they do at a moment’s notice to keep the rest of their teams and community safe. Their many hardships are well overdue for our respect and recognition.</p>
<hr>
<p><em>Tracey Johnson, CEO of Inala Primary Care, a large GP clinic and charity in Queensland, contributed to this article.</em></p><img src="https://counter.theconversation.com/content/160532/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lauren Ball receives funding from the National Health and Medical Research Council, RACGP Foundation, VicHealth and Queensland Health. Lauren is an Executive Committee member of the Australasian Association of Academic Primary Care and on the Editorial Advisory Committee of the Australian Journal of General Practice. </span></em></p><p class="fine-print"><em><span>David is an Executive Committee member of the Australasian Association of Academic Primary Care.</span></em></p><p class="fine-print"><em><span>Katelyn Barnes is an Executive Committee member of the Australasian Association of Academic Primary Care.</span></em></p>Medical receptionists have taken on new roles during the pandemic, which no-one planned for. We must not forget them and the stressful work they do.Lauren Ball, Associate Professor/ Principal Research Fellow, Griffith UniversityDavid Chua, Primary heath care research fellow, Griffith UniversityKatelyn Barnes, Postdoctoral Research Fellow, Griffith UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1587892021-04-14T01:04:48Z2021-04-14T01:04:48ZDoctors do not face a greater legal risk if they give AstraZeneca to younger Australians — here’s why<figure><img src="https://images.theconversation.com/files/394714/original/file-20210413-15-hxbl18.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Simon Santi/AAP</span></span></figcaption></figure><p>Last week, the federal government changed its <a href="https://www.health.gov.au/news/atagi-statement-on-astrazeneca-vaccine-in-response-to-new-vaccine-safety-concerns">recommendation</a> for COVID-19 vaccines. The Pfizer vaccine is now the “preferred” jab for adults under 50. </p>
<p>Amid the <a href="https://theconversation.com/as-australias-vaccination-bungle-becomes-clear-morrisons-political-pain-is-only-just-beginning-158704">political fallout</a> and worries about what it means for Australia’s COVID recovery, doctors have expressed concern about their liability. Some said they would even <a href="https://www.smh.com.au/national/doctors-stop-offering-astrazeneca-jabs-over-legal-risk-20210410-p57i5f.html">stop giving the AstraZeneca jab</a> until they were more certain of their position.</p>
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Read more:
<a href="https://theconversation.com/new-astrazeneca-advice-is-a-safer-path-but-its-damaged-vaccine-confidence-the-government-must-urgently-restore-it-158763">New AstraZeneca advice is a safer path, but it's damaged vaccine confidence. The government must urgently restore it</a>
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<p>Are they at greater legal risk if they give AstraZeneca to younger Australians? The government <a href="https://www1.racgp.org.au/newsgp/professional/no-legal-risk-for-gps-administering-astrazeneca-va">insists</a> they are not. This is correct — here’s why.</p>
<h2>Proving fault</h2>
<p>In Australia, medical liability is, for the most part, fault-based. This means patients who are injured by medicines, medical devices and medical interventions must prove the doctors who used them were to blame for any injury they suffered before any compensation will be paid. </p>
<p>Australian liability laws are state-based, but generally speaking, fault can only be proven when the doctor has acted outside of the professional standard of care in a way that is not supported widely in Australia by professional peers.</p>
<h2>What is the standard of care?</h2>
<p>The standard of care for diagnosis and treatment is effectively set by the medical profession. In cases — such as COVID vaccines — where the treatment is new and knowledge about the treatment is emerging, the standard of care is also developing. </p>
<p>Importantly, doctors are judged by measuring their behaviour against the standard of care at the time the treatment was given. This means that if, in 2020 a doctor administers a COVID vaccine in a way that was supported by their peers at that time, they will not be found to have breached the standard of care if, years later, other side effects become known.</p>
<figure class="align-center ">
<img alt="Prime Minister Scott Morrison inspecting AstraZeneca production." src="https://images.theconversation.com/files/394716/original/file-20210413-19-3lxa67.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/394716/original/file-20210413-19-3lxa67.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=415&fit=crop&dpr=1 600w, https://images.theconversation.com/files/394716/original/file-20210413-19-3lxa67.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=415&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/394716/original/file-20210413-19-3lxa67.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=415&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/394716/original/file-20210413-19-3lxa67.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=522&fit=crop&dpr=1 754w, https://images.theconversation.com/files/394716/original/file-20210413-19-3lxa67.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=522&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/394716/original/file-20210413-19-3lxa67.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=522&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Last week the Morrison government changed its advice around the AstraZeneca vaccine.</span>
<span class="attribution"><span class="source">David Caird/AAP</span></span>
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<p>We should also be careful not to automatically equate the government’s advice concerning the AstraZeneca vaccine with what the standard of care should be at the individual level. </p>
<p>The government’s advice is concerned with the big picture and with risks across a population. Doctors have the task of treating individuals. So, the government’s advice should be considered by doctors when working out which vaccines to offer to patients, but there may well be situations where the AstraZeneca is the best option for individual adult patients under 50.</p>
<h2>Giving advice and accepting risks</h2>
<p>Doctors also have a duty to inform individual patients about material risks of the treatments they provide. Every intervention comes with a set of risks but only the material ones need to be disclosed. </p>
<p>Material risks include those the profession would usually notify patients of (objective material risks), as well as risks the individual patient may have a particular concern about (subjective material risks). </p>
<p>The classic example of this is the 1993 case of <a href="https://pubmed.ncbi.nlm.nih.gov/11648609/">Rogers v Whitaker</a> where a woman who was blind in one eye was considering cosmetic surgery on that eye. She was concerned about any risk (no matter how remote) of going blind in her “good eye”. Later, she became blind from a complication of her treatment, which was known but very rare. The doctor’s failure to inform her was considered a breach of the duty to inform — even though it was not a risk normally disclosed — because the risk was subjectively material to her. </p>
<p>Again, the doctor will always be judged by what the profession knew at the time regarding these risks. If a patient is told about the material risks of the treatment and decides to go ahead with the treatment, the doctor has satisfied their legal duty to advise and cannot be held liable for subsequent injuries.</p>
<h2>What now for GPs and AstraZeneca?</h2>
<p>As long as doctors consider the government advice, keep up with professional news about best practice and communicate material risks to patients, they face no greater liability for providing COVID vaccines than they do for any other treatment. </p>
<p>The reality is the risks of people being injured by vaccines, and of doctors being sued for vaccine-related injury, is incredibly low.</p>
<p>At the weekend, the <a href="https://www.abc.net.au/news/2021-04-11/covid-live-blog-coronavirus-latest-news/100061512">Australian Medical Association</a> also said if a patient makes an informed decision to receive the AstraZeneca vaccine, GPs are protected under professional indemnity insurance. </p>
<p>Of course, the reality of low risk may not match the fear practitioners experience. So, are there things we can do to reduce the anxiety practitioners feel regarding liability?</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/bad-reactions-to-the-covid-vaccine-will-be-rare-but-australians-deserve-a-proper-compensation-scheme-150288">Bad reactions to the COVID vaccine will be rare, but Australians deserve a proper compensation scheme</a>
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<p>One obvious measure is to move to no-fault systems of compensation. Many countries including the United States and New Zealand have no-fault compensation schemes for vaccine-related injury. Putting such a scheme in place may very well help doctors get over the fear of being sued. It might also give patients confidence knowing that in an extremely rare case of injury, they will be covered. </p>
<p>This could be done either with a one-off scheme or by expanding the <a href="https://treasury.gov.au/programs-initiatives-consumers-community/niis">National Injury Insurance Scheme</a>, which covers personal injuries from motor vehicle accidents.</p>
<p>Without such schemes, Australian patients will only have access to compensation for vaccine-related injury if they can prove it was caused by a failure to act according to medical standards of care or a failure to properly inform the patient of material risks.</p><img src="https://counter.theconversation.com/content/158789/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cameron Stewart does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Generally speaking, fault can only be proven when the doctor has acted outside of the professional standard of care.Cameron Stewart, Professor at Sydney Law School, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1541772021-02-03T03:46:50Z2021-02-03T03:46:50ZShould GPs charge for bandages or dressings? Hunt says no to ‘band-aid tax’. So here are some other options<figure><img src="https://images.theconversation.com/files/382088/original/file-20210202-15-dafd7t.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C667&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/medical-assistant-applying-gauze-bandage-onto-623834861">from www.shutterstock.com</a></span></figcaption></figure><p>Federal Health Minister Greg Hunt recently <a href="https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/doorstop-interview-on-31-january-2021">ruled out</a> GP patients having to pay for bandages and dressings, despite a major Medicare review recommending it.</p>
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<p>We won’t be putting in place extra charges for patients. I am ruling that out.</p>
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<p>Hunt was commenting on a <a href="https://www.health.gov.au/resources/publications/report-from-the-wound-management-working-group">recommendation</a> from the Medicare Benefits Schedule Review Taskforce to charge bulk-billed patients for bandages and dressings. The idea was to save patients some money at the pharmacy, where such products can be expensive. The recommendation also addressed <a href="https://medicalrepublic.com.au/wound-dressings-may-soon-to-be-covered/25714">some GPs’ concerns</a> they were out of pocket by supplying these items. However, some people <a href="https://twitter.com/SwannyQLD/status/1355669803822850052">had called</a> the recommendation to charge patients a “<a href="https://twitter.com/australiandr/status/1356090593919729670">band-aid tax</a>”.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1355780810067091456"}"></div></p>
<p>Rather than charging patients, Hunt said <a href="https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/doorstop-interview-on-31-january-2021">he’d discuss</a> “alternative sources of government support” for general practices and doctors to supply these items. Here are some options and what they could mean for you.</p>
<h2>A thin end of the wedge?</h2>
<p>Since 2015, the taskforce has been <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/MBSReviewTaskforce">reviewing about 5,700 items</a> on the Medicare Benefits Schedule to see which services you receive at your GP or specialist align with current evidence and practice, are safe and might benefit you.</p>
<p>Of its <a href="https://www.health.gov.au/resources/publications/medicare-benefits-schedule-review-taskforce-final-report">1,400 or more recommendations</a>, this one initially seems to be the thin end of the wedge. What would GPs charge you for next? Using equipment to take your blood pressure? The paper your bill is printed on? Luckily, separate charges for such items are <a href="https://www.croakey.org/fatal-wound-for-medicare-new-fees-for-dressings-herald-the-end-of-bulk-billing/">illegal</a>.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/medicare-review-must-deal-with-elephant-in-the-room-incentives-40819">Medicare review must deal with 'elephant in the room' incentives</a>
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<p>GPs can already choose to charge any amount for a consultation. And you would presume all GPs’ costs — including rent for their premises, equipment, office chairs, as well as consumables such as bandages and dressings — are considered when they decide on the level of fee to charge, or whether to bulk-bill. If the costs of supplies are increasing, then GPs can simply increase the consultation fee.</p>
<p>The recommendation also seemed inconsistent with the objectives of the review. This included trying to simplify the Medicare Benefits Schedule (not making it <a href="https://www.croakey.org/fatal-wound-for-medicare-new-fees-for-dressings-herald-the-end-of-bulk-billing/">more complicated</a>). The recommendation also seemed inconsistent with strong recommendations aimed at reducing patients’ out-of-pocket costs and making health care more affordable.</p>
<h2>What was the taskforce thinking?</h2>
<p>The taskforce argued people with chronic wounds, such as <a href="https://www.betterhealth.vic.gov.au/health/ConditionsAndTreatments/leg-ulcers">venous leg ulcers</a>, often paid a lot for wound dressings they used at home.</p>
<p>Though GPs and practice nurses help dress wounds, patients still need to regularly manage and dress wounds themselves at home. So the taskforce was arguing these costs should be subsidised.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/curious-kids-how-do-wounds-heal-118603">Curious Kids: how do wounds heal?</a>
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</em>
</p>
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<p>The recommendation to allow GPs to charge patients was where the consultation was bulk-billed. This seemed to assume this would be cheaper for patients rather than them buying their own dressings from pharmacies and supermarkets. So the intention was to reduce out-of-pocket costs overall. </p>
<p>However, this recommendation relies on GPs charging patients less than what pharmacies or supermarkets may charge and GPs would not try to profit from selling dressings to patients. However, the taskforce presented no evidence or data to show this would be the case, even though its recommendations are supposed to be evidence-based.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Bandages and dressings on supermarket shelf" src="https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=425&fit=crop&dpr=1 754w, https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=425&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/382095/original/file-20210202-17-14xbotj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=425&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The taskforce thought patients could save money by going to their GP for their dressings rather than buying them at the pharmacy or supermarket.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/shah-alam-malaysia-9-june-2019-1419324386">www.shutterstock.com</a></span>
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<h2>Managing wounds well has both health and economic benefits</h2>
<p>Inadequate wound care can have debilitating effects and adversely influence people’s mobility and quality of life. Like any health-care treatment, keeping out-of-pocket costs low for patients can help improve access to health care and improve health outcomes. The issue is how to do this.</p>
<p>Treatment is also <a href="https://link.springer.com/article/10.1186/s12913-018-3234-3">highly cost-effective</a>. For instance, providing compression therapy products, such as compression bandages for leg ulcers, would cost the health system an additional A$270 million over five years. But it would save about $1.4 billion over the same period.</p>
<p>So it seems to make sense for new policies to try and reduce the costs GP practices and patients face for these supplies.</p>
<h2>How do we reduce the costs?</h2>
<p><strong>Centralise purchasing</strong></p>
<p>GP practices and pharmacies buy their supplies on the open market, and small GP practices may not be able to get good deals. </p>
<p>So the taskforce also recommended a Commonwealth-funded wound consumables scheme to centralise purchasing and price negotiation, as is done for medical devices and pharmaceuticals at the Commonwealth level. The idea is to keep prices low.</p>
<p><strong>Offer discounts</strong></p>
<p>Certain patients with chronic wounds could also be eligible for heavily discounted dressings from their pharmacy, though this may be difficult for less-mobile patients. GPs could “prescribe” which dressings are needed and for how long, and the pharmacies could “dispense” these for patients from the wound consumables scheme. </p>
<p><strong>Rethink dispensing</strong></p>
<p>GPs could also dispense these dressings themselves. For eligible patients who are not mobile and cannot easily visit pharmacies, GPs could provide and apply dressings for chronic wounds in the practice (or through practice nurses visiting patients at home). GPs could also provide dressings for patients to apply at home. Providing dressings at home or in the GP practice would require additional payments to general practices from Medicare.</p>
<p>This payment would need to provide incentives for GPs to manage the wounds more effectively and to buy high-quality, low-cost dressings, perhaps purchased via the wound consumables scheme.</p>
<h2>What needs to happen?</h2>
<p>For patients with chronic wounds that need long-term care (not just people wanting a band-aid), reducing the costs of bandages and dressings is likely to improve access and improve outcomes. </p>
<p>Examining the regulation of these markets could be a first step to ensure prices are as low as possible. This could include considering more centralised purchasing, followed by considering additional funding to subsidise these very cost-effective treatments.</p><img src="https://counter.theconversation.com/content/154177/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anthony Scott receives funding for research grants from NHMRC, ARC, and Medibank Better Health Foundation.</span></em></p>Wound care might be costly, but it’s cost-effective, saving health dollars in the long run. The issue is, who pays?Anthony Scott, Professor, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1537962021-01-31T18:55:13Z2021-01-31T18:55:13ZDoctors must now prescribe drugs using their chemical name, not brand names. That’s good news for patients<figure><img src="https://images.theconversation.com/files/381267/original/file-20210129-21-1wumjzy.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6006%2C4007&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shuterstock</span></span></figcaption></figure><p>From today (February 1), when you receive a prescription in Australia, it will list the name of the medication’s <a href="https://www.pbs.gov.au/info/general/active-ingredient-prescribing">active ingredient</a> rather than the brand name. So, for example, instead of receiving a prescription for Ventolin, your script will say “salbutamol”. </p>
<p>This national legislation change, called <a href="https://www.safetyandquality.gov.au/sites/default/files/2020-12/fact_sheet_-_active_ingredient_prescribing_-_guidance_for_australian_prescribers_0.pdf">active ingredient prescribing</a>, is long overdue for Australian health care. </p>
<p>Using the name of the drug — instead of the brand name, of which there are often many — will simplify how we talk about and use medications. </p>
<p>This could have a range of benefits, including fewer <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/imj.12805">medication errors</a> by both doctors and patients.</p>
<h2>What is an active ingredient?</h2>
<p>The <a href="https://www.tga.gov.au/book/prominence-active-ingredients-medicine-labels">active ingredient</a> describes the main chemical compound in the medicine that affects your body. It’s the ingredient that helps control your asthma or headache, for example. </p>
<p>Drugs are tested to ensure they contain exactly <a href="https://www.tga.gov.au/publication/australian-regulatory-guidelines-prescription-medicines-argpm">the same active ingredients</a> regardless of which brand you buy.</p>
<p>There’s only one active ingredient name for each type of medical compound, although they may come in different strengths. Some types of medications may contain multiple active ingredients, such as Panadeine Forte, which contains both paracetamol and codeine.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/prescribing-generic-drugs-will-reduce-patient-confusion-and-medication-errors-77093">Prescribing generic drugs will reduce patient confusion and medication errors</a>
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<h2>There can be several brand names</h2>
<p>Until now, doctors and other prescribers have used a mixture of brand and active ingredient names when prescribing medicines. An Australian study found doctors used brand names for <a href="https://www.publish.csiro.au/AH/AH12009">80.5% of prescriptions</a>. </p>
<p>Different brands are available for most medications — <a href="https://www.mja.com.au/journal/2011/195/11/whats-name-brand-name-confusion-and-generic-medicines">up to 12</a> for some. Combined with active ingredient names, this equates to thousands of different names — too many for any patient, doctor, nurse or pharmacist to remember. </p>
<figure class="align-center ">
<img alt="A senior man taking a tablet. There are a variety of medications on the table." src="https://images.theconversation.com/files/381268/original/file-20210129-23-15x62ie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/381268/original/file-20210129-23-15x62ie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=394&fit=crop&dpr=1 600w, https://images.theconversation.com/files/381268/original/file-20210129-23-15x62ie.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=394&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/381268/original/file-20210129-23-15x62ie.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=394&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/381268/original/file-20210129-23-15x62ie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=495&fit=crop&dpr=1 754w, https://images.theconversation.com/files/381268/original/file-20210129-23-15x62ie.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=495&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/381268/original/file-20210129-23-15x62ie.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=495&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Older people are at higher risk of making medication errors, as they tend to take more medications.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Here’s an example of the problem.</p>
<p>I ask John, a patient whom I’ve just met, whether he takes cholesterol medications, commonly called statins. The active ingredient names for this group of medications all end in “statin” (for example, pravastatin, simvastatin).</p>
<p>“Ummm, I’m not sure, is it a blue pill?” John asks.</p>
<p>“It could come in many colours. It might be called atorvastatin, or Lipitor,” I reply. “Perhaps rosuvastatin, or Crestor, or Zocor?”</p>
<p>“Ah yes, Crestor, I am taking that,” John exclaims, after deliberating for some time.</p>
<p>This is a common and important conversation, but could be simpler for both of us if John was familiar with the active ingredient name.</p>
<p>And while we did eventually come to the answer, this medication could have easily been overlooked, by both John and myself. This may have significant implications and interact with other medicines I might prescribe.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/ive-heard-covid-is-leading-to-medicine-shortages-what-can-i-do-if-my-medicine-is-out-of-stock-153628">I've heard COVID is leading to medicine shortages. What can I do if my medicine is out of stock?</a>
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<h2>Cause for confusion</h2>
<p>The main problem with using brand names for medications is the potential for confusion, as we see with John.</p>
<p>A prescription written using a brand name doesn’t mean you can’t buy other brands. And your pharmacist may offer to substitute the brand specified for an equivalent generic drug. So, people often leave the pharmacy with a medication name or package that bears no resemblance to the prescription.</p>
<p>When the terms we use to describe medicines in conversation, on prescriptions and what’s written on the medication packet can all be different, patients might not understand which medications they’re taking, or why. </p>
<p>This often leads to doubling up (taking two brands of the same medication), or forgetting to take a certain medication because the name on the package doesn’t match what’s written on your medication list or prescription.</p>
<p>Confusion resulting from using brand names has been associated with serious medication errors, including <a href="https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/211398?casa_token=hA41G4MI1ZQAAAAA:JJTT5NB6FOTsn-ZluZclU9Xxx942FN1mcbjcJ-zJlhJ6SNJc8GoIL0eyE1fdb55JV1s1gzu9aNg">overdoses</a>. Elderly people are the most susceptible, as they’re most likely to take multiple medications.</p>
<p>Even when the confusion doesn’t cause harm, it can be problematic in other ways. If patients don’t understand their medicines, they may be less likely to be proactive in making decisions with their doctor or pharmacist about their health care.</p>
<p>Health professionals can also get confused, potentially leading to <a href="https://www.ismp.org/resources/progress-preventing-name-confusion-errors">prescribing errors</a>.</p>
<h2>What are the benefits of active ingredient prescribing?</h2>
<p>The main benefit of the switch is to simplify the language around medications. </p>
<p>Once we become accustomed to using one standardised name for each medicine, it will be easier to talk about medicines, whether with a family member, pharmacist or doctor. </p>
<p>The better we understand the medications we’re using, the <a href="https://www.sciencedirect.com/science/article/pii/S0025619614003875?casa_token=s6dZMe3HH58AAAAA:ZEY1c6ltPyfJBMuOw6XHH6PdGdAuLpkn6s3WP0gmoSo8UwC7pD-vpwMwqqjp81V9KCbp6PcTtw">fewer errors we make</a>, and the more control we can take over our medication use and decisions.</p>
<figure class="align-center ">
<img alt="A pharmacist studies a woman's prescription." src="https://images.theconversation.com/files/381269/original/file-20210129-13-6xid6s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/381269/original/file-20210129-13-6xid6s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/381269/original/file-20210129-13-6xid6s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/381269/original/file-20210129-13-6xid6s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/381269/original/file-20210129-13-6xid6s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/381269/original/file-20210129-13-6xid6s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/381269/original/file-20210129-13-6xid6s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A pharmacist can let you know which brands of your medication are are available.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>This change will also serve to promote choice.</p>
<p>When you’re prescribed a medicine with a certain name, you’re more likely to buy that brand. In some cases there may be generic medicines that are cheaper and just as effective. Or there may be other forms of the medication that better suit your needs, such as a capsule only available in another brand.</p>
<h2>Not too much will change</h2>
<p>This new rule is not expected to lead to extra work for doctors, pharmacists or other health professionals who prescribe medicines, as most clinical software will make the transition automatically.</p>
<p>Doctors can elect to still include the brand name on the prescription, if they feel it’s important for the patient. But aside from some limited exceptions, the active ingredient name will need to be listed, and will be listed first.</p>
<p>Some active ingredient names may be a bit longer and more complex than certain brand names, so there might be a period of adjustment for consumers. </p>
<p>But in the long term, this change will streamline terminology around medicines and make things easier, and hopefully safer, for everyone.</p>
<p>Next time you receive your prescription, have a look at the name of the active ingredient. Remember it, and use that name when you talk to your family, doctor and pharmacist.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/boomers-have-a-drug-problem-but-not-the-kind-you-might-think-127682">Boomers have a drug problem, but not the kind you might think</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/153796/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Matthew Grant received funding from the National Health and Medical Research Council.</span></em></p>The language used to describe medications is confusing, with multiple names for the same drug. A change to prescribing rules from today should go a long way to addressing this issue.Matthew Grant, Palliative Medicine Physician, Research Fellow, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1240832019-12-17T19:04:01Z2019-12-17T19:04:01ZYour first point of contact and your partner in recovery: the GP’s role in mental health care<figure><img src="https://images.theconversation.com/files/307378/original/file-20191217-164420-1dnzlez.jpg?ixlib=rb-1.1.0&rect=15%2C0%2C5063%2C3380&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">GPs see 88% of the Australian population every year. So they're well-positioned to provide mental health care to a broad spectrum of people.</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>Around <a href="https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia-in-brief-2018/formats">70% of people</a> who sought treatment for their mental health in Australia in 2015-16 saw a general practitioner. This amounts to <a href="https://www.aihw.gov.au/reports-data/health-welfare-services/mental-health-services/overview">18 million dedicated mental health consultations</a>.</p>
<p>GPs are often the first point of contact for people concerned about their mental health. Mostly, though, mental health care occurs within consultations initiated for other reasons. This could be when someone sees a doctor for a physical health concern, a general check up, or to get a prescription.</p>
<p>Whatever the reason, GPs see <a href="https://www.racgp.org.au/download/Documents/Publications/Health-of-the-Nation-2018-Report.pdf">88% of the Australian population every year</a>, putting us in a <a href="https://www1.health.gov.au/internet/publications/publishing.nsf/Content/mental-pubs-p-mono-toc%7Emental-pubs-p-mono-bas%7Emental-pubs-p-mono-bas-acc%7Emental-pubs-p-mono-bas-acc-pri">unique position in the health system</a> to work with people with mental health concerns.</p>
<p>When you visit your GP with a mental health concern, you should be able to expect compassionate care alongside practical advice to help you navigate the treatment you need.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/depression-its-a-word-we-use-a-lot-but-what-exactly-is-it-122381">Depression: it’s a word we use a lot, but what exactly is it?</a>
</strong>
</em>
</p>
<hr>
<h2>Why see a GP for your mental health needs?</h2>
<p>People can see us without a referral, and we get to know our patients over time, which can make it easier to discuss difficult issues. </p>
<p>We see patients during important transitions, for example after giving birth, after a major illness, or during a relationship crisis. </p>
<p>We also see people at higher risk of mental illness than the overall population, such as <a href="https://www1.racgp.org.au/newsgp/professional/%E2%80%98someone-needs-to-say,-enough%E2%80%99-mental-health-on-ma">refugees</a>, <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/MentalHealthServices/Report/c04">Aboriginal and Torres Strait Islander Australians</a>, <a href="https://www.racgp.org.au/clinical-resources/clinical-guidelines/guidelines-by-topic/view-all-guidelines-by-topic/lgbti-health/a-guide-to-sensitive-care">LGBTI people</a>, and those experiencing <a href="https://www.racgp.org.au/publications/goodpractice/201707/homeless-healthcare/">poverty and homelessness</a>. Many of our patients are <a href="https://www.blueknot.org.au/Resources/Information/Understanding-abuse-and-trauma/What-is-complex-trauma/Complex-Trauma-and-mental-health">survivors of childhood abuse</a>, <a href="https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/rp/rp1415/ViolenceAust">domestic violence</a>, or other forms of trauma. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/307318/original/file-20191217-124041-1yhvp92.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/307318/original/file-20191217-124041-1yhvp92.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=365&fit=crop&dpr=1 600w, https://images.theconversation.com/files/307318/original/file-20191217-124041-1yhvp92.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=365&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/307318/original/file-20191217-124041-1yhvp92.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=365&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/307318/original/file-20191217-124041-1yhvp92.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=459&fit=crop&dpr=1 754w, https://images.theconversation.com/files/307318/original/file-20191217-124041-1yhvp92.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=459&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/307318/original/file-20191217-124041-1yhvp92.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=459&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">If you have a mental illness, you may need treatment beyond what a GP can provide. But a GP can help you understand your options.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
</figcaption>
</figure>
<p>We understand certain physical illnesses and medications can <a href="https://psychcentral.com/lib/the-relationship-between-mental-and-physical-health/">predispose people to mental illness</a>. We also understand people with serious mental illnesses are likely to <a href="https://theconversation.com/stroke-cancer-and-other-chronic-diseases-more-likely-for-those-with-poor-mental-health-100955">die from physical diseases</a> up to <a href="https://www.news.com.au/lifestyle/health/mind/the-big-health-problem-thats-slashing-decades-off-australian-life-expectancies/news-story/171c8fe015bf5b1a74678d801cd22f5c">20 years earlier than the general population</a>. So we can focus on <a href="https://theconversation.com/physical-health-ignored-in-people-with-mental-illness-69040">physical and mental health together</a>.</p>
<p>We are trained in diagnosis, but we understand mental health is complex. Not everyone with depression has the <a href="https://theconversation.com/depression-its-a-word-we-use-a-lot-but-what-exactly-is-it-122381">same illness experience</a>. It’s critical we help people understand what their illness means, not just what it “is”.</p>
<p>It’s then our responsibility to help our patients understand their options, by communicating the evidence behind different treatments, and helping them navigate the mosaic of services available. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/stroke-cancer-and-other-chronic-diseases-more-likely-for-those-with-poor-mental-health-100955">Stroke, cancer and other chronic diseases more likely for those with poor mental health</a>
</strong>
</em>
</p>
<hr>
<h2>Finding the right clinic and the right doctor</h2>
<p>The billings we generate in the consulting room fund our clinics and our staff. The longer the consultation, the <a href="https://theconversation.com/explainer-what-is-medicare-and-how-does-it-work-22523">lower the patient’s Medicare subsidy per minute</a>. In other words, shorter consultations earn much more money for the clinic. </p>
<p>Some bulk-billing clinics use this incentive to drive what’s become known as “<a href="https://www.smh.com.au/national/bulk-billing-clinics-turning-away-complex-patients-20180704-p4zpij.html">six-minute medicine</a>”: where the majority of consultations are very quick and therefore lucrative. These business models don’t enable complex care, like the sort of care needed to deal with a mental health issue, to occur easily. </p>
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<p><iframe id="ETufI" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/ETufI/6/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
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<p>Further, individual GPs have certain areas of practice that interest them. Some GPs are <a href="https://www.blackdoginstitute.org.au/docs/default-source/factsheets/findingamentalhealthfriendlydoctor_final.pdf?sfvrsn=2">more interested in and comfortable with physical health</a> than mental health care.</p>
<p>Consumers have reported <a href="https://healthtalkaustralia.org/supported-decision-making/experiences-with-gps/#a4">disappointing encounters with some GPs</a>, describing, for example, poor communication skills and a perceived lack of competence in mental health care. </p>
<p>It’s important to take the time to find a clinic and a GP right for you.</p>
<h2>Navigating a fraught system</h2>
<p>The mental health sector is <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/mental-fifth-national-mental-health-plan">complex and fragmented</a> with <a href="http://mentalhealthcommission.gov.au/our-reports/our-national-report-cards/2014-contributing-lives-review.aspx">overlaps, inefficiencies, duplication and poor coordination of services</a>. GPs spend a significant amount of time assisting patients to navigate multiple mental health systems (state services, Commonwealth services, non-government services, and private services).</p>
<p>We often have few accessible resources at our disposal to help our patients recover. Psychologists and other allied health practitioners are frequently <a href="https://theconversation.com/when-its-easier-to-get-meds-than-therapy-how-poverty-makes-it-hard-to-escape-mental-illness-114505">unaffordable or inaccessible</a>. There’s a <a href="https://submissions.education.gov.au/forms/archive/2015_16_sol/documents/Attachments/Royal%20Australasian%20College%20of%20Surgeons.pdf">shortage of psychiatrists in Australia</a>. <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Former_Committees/mentalhealth/report/c08">Acute psychiatric beds</a>, particularly for <a href="https://theconversation.com/3-out-of-4-kids-with-mental-health-disorders-arent-accessing-care-118597">young people</a> or <a href="https://www.abc.net.au/news/2012-10-01/27lives-at-risk27-through-lack-of-eating-disorder-beds/4289502">patients with eating disorders</a>, are in short supply.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/to-really-fix-victorias-mental-health-system-well-need-to-bridge-the-state-commonwealth-divide-127993">To really fix Victoria's mental health system, we'll need to bridge the state/Commonwealth divide</a>
</strong>
</em>
</p>
<hr>
<p>Meanwhile, disadvantaged communities have <a href="https://www.mja.com.au/journal/2015/202/4/better-access-mental-health-care-and-failure-medicare-principle-universality">higher rates of mental illness</a>, but lower access to services.</p>
<p>Unfortunately, none of these problems will be solved within a GP’s consulting room – but we do our best to navigate them case by case. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/304195/original/file-20191128-176634-15s1fj3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/304195/original/file-20191128-176634-15s1fj3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/304195/original/file-20191128-176634-15s1fj3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/304195/original/file-20191128-176634-15s1fj3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/304195/original/file-20191128-176634-15s1fj3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/304195/original/file-20191128-176634-15s1fj3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/304195/original/file-20191128-176634-15s1fj3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Understanding the mosaic of services available for mental health can be challenging.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
</figcaption>
</figure>
<h2>10 tips for patients</h2>
<p>We believe the core of mental health care is a <a href="https://www.bridgestorecovery.com/blog/in-it-together-the-importance-of-the-therapeutic-alliance/">consistent, empathic therapeutic relationship</a> to support consumers in their journey towards recovery.</p>
<p>Every consumer has the right to find a GP who can partner in that recovery. These tips will help you get the most out of your GP mental health consultation:</p>
<ol>
<li> if you can, make a longer appointment. Mental health consultations take time</li>
<li> choose a GP carefully. You need to feel comfortable with them</li>
<li> consider taking a supportive friend or relative with you</li>
<li> if waiting rooms are stressful for you, consider timing your appointment at the beginning or end of the day</li>
<li> have a list of medications and therapies you’ve tried, and whether you found them helpful</li>
<li> if you have any reports from previous doctors, bring them with you</li>
<li> your GP will want to know your family history, including physical and mental health disorders, so find out what you can</li>
<li> be as honest and open as you can. Your GP can help you more effectively if they know what’s going on. This includes drug and alcohol issues which commonly accompany mental illness</li>
<li> if you need an interpreter, let the practice know in advance</li>
<li>be patient. It may take a few consultations for your GP to really understand what you need.</li>
</ol>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/when-its-easier-to-get-meds-than-therapy-how-poverty-makes-it-hard-to-escape-mental-illness-114505">When it's easier to get meds than therapy: how poverty makes it hard to escape mental illness</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/124083/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Louise Stone does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Navigating the mosaic of mental health services available is hard. A GP can help.Louise Stone, General practitioner; Clinical Associate Professor, ANU Medical School, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/935222018-04-13T13:49:21Z2018-04-13T13:49:21ZRepeat prescriptions are expensive and time consuming – it’s time for an NHS rethink<figure><img src="https://images.theconversation.com/files/211738/original/file-20180323-54863-99b0bv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">And repeat.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/drug-prescription-treatment-medication-pharmaceutical-medicament-544348294?src=Pt2C-eiYews1VpI5kIYHZA-1-33">Shutterstock</a></span></figcaption></figure><p>Over a billion NHS prescription medicines are issued by pharmacists in England every year – at a <a href="https://digital.nhs.uk/catalogue/PUB23631">cost of over £9 billion</a>. Many of these are prescribed by GPs to manage long-term health conditions, such as diabetes or cardiovascular disease.</p>
<p>The current “repeat prescription” system allows patients to request a further supply of medicines without the inconvenience of another doctor’s appointment. </p>
<p>The <a href="http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/Browsable/DH_4892136">UK Department of Health advises</a> that the frequency of repeat prescriptions should “balance patient convenience with clinical appropriateness, cost-effectiveness and patient safety”. </p>
<p>However, it does not recommend a specific time period. As a result, local health service commissioners have developed their own guidance, with many encouraging GPs to issue short-term supplies of repeat medications, typically 28 days in length. This is supported by the UK’s <a href="http://psnc.org.uk/services-commissioning/psnc-briefings-services-and-commissioning/psnc-briefing-05416-medicines-wastage-and-prescription-duration-october-2016/">Pharmaceutical Services Negotiating Committee</a>.</p>
<p>One of the key reasons for issuing monthly supplies is the opportunity to reduce medication waste, which has been previously estimated to cost the NHS <a href="https://www.bristolccg.nhs.uk/media/medialibrary/2016/02/Report_Medicines_Waste_in_Bristol.pdf">around £300m a year</a> in England alone. If patients have fewer pills in their possession, it is harder to mislay or stockpile them. </p>
<p>It is also possible that fairly frequent contact with the doctor may aid the discovery of potential drug intolerance, and provide more chances for medication review.</p>
<p>But is this approach the right one? From the perspective of patients, shorter prescriptions also mean more opportunities to forget to reorder supplies, and often necessitate additional trips to the GP and pharmacy. </p>
<p>Time and effort spent dispensing pills in community pharmacies is also considerable, and arguably an inefficient use of pharmacists’ valuable skills. Shorter prescription time frames exacerbate this. The workload for GPs authorising further prescriptions can also be substantial.</p>
<p>Our <a href="https://njl-admin.nihr.ac.uk/document/download/2011885">recent research</a> challenges the current practice of shorter repeat prescriptions. We identified evidence from <a href="https://bjgp.org/content/early/2018/03/12/bjgp18X695501">nine reports</a> suggesting that longer duration prescriptions are associated with better adherence by patients to their medications (in other words, patients are more likely to take their pills the way the doctor intended). </p>
<p>A <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3534845/">single American study</a> of statins, a drug commonly prescribed to patients with cardiovascular disease, even found improvements in lipid control with longer term prescriptions. (However, other studies examining health outcomes or patient experience were lacking.)</p>
<p>In analysing 11 years of UK <a href="http://bmjopen.bmj.com/content/7/12/e019382">GP prescribing data</a>, we found that shorter prescriptions were indeed associated with reduced medication waste. But those savings were more than offset by greater costs due to the additional work required by GPs and pharmacists. </p>
<p>Consider, for example, the impact of switching statins – the most widely prescribed drugs in UK primary care – to longer durations of around three months. This has the potential to save over £500m per year in doctor and pharmacist time – precious GP time which could be ploughed back into a struggling health service, seeing patients rather than signing bits of paper. </p>
<p>One could argue that the growth of electronic repeat dispensing, where GPs can authorise multiple repeat prescriptions at a time, could help deal with this issue. But there is still the opportunity for over £60m in savings through reduced dispensing costs for these drugs alone. </p>
<p>An <a href="https://link.springer.com/article/10.1007%2Fs40258-018-0383-9">economic modelling exercise</a> found longer term prescriptions to be more cost-effective than shorter ones, driven primarily through health gains due to better medication adherence. </p>
<p>Medications are a daily part of the lives of millions, and in many cases unavoidable. Yet the current recommendations that require patients to make monthly trips to pick up more pills are simply not justified by the evidence. </p>
<p>There is the potential for longer prescriptions to lead to important benefits, by improving patients’ adherence and thus the effectiveness of the drugs, lessening workload for health care professionals, and reducing inconvenience and costs to patients.</p>
<h2>A bitter pill?</h2>
<p>News that issuing longer prescriptions is more cost effective is likely to be welcomed by most GPs. But pharmacists may be less enthusiastic. </p>
<p>Community pharmacies receive dispensing fees for each NHS prescription, so reducing the frequency could lead to a large reduction in income. The NHS may save money, but critical pharmacy services could suffer. Changes to national policy around the length of repeat prescriptions would therefore need to consider how pharmacies are reimbursed. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/214249/original/file-20180411-570-819oki.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/214249/original/file-20180411-570-819oki.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/214249/original/file-20180411-570-819oki.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/214249/original/file-20180411-570-819oki.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/214249/original/file-20180411-570-819oki.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/214249/original/file-20180411-570-819oki.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/214249/original/file-20180411-570-819oki.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">What if the drugs don’t work?</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/newbury-berkshire-england-november-3-2017-755878630?src=pTc5K-y3YVlW_UbMQZXYIQ-1-4">Shutterstock</a></span>
</figcaption>
</figure>
<p>Simply increasing the dispensing fee will not be straightforward, as some drugs may be more suitable for switching to longer prescriptions than others. It may not be possible, either, to recommend a new, standardised, longer prescription length. </p>
<p>Further research is likely to show that the one-size-fits-all model of 28 day blanket prescription policy is unsustainable. Different conditions, drugs and patient profiles may require different prescription lengths. </p>
<p>There are undoubtedly limitations to the work we have carried out so far, and it is necessary to make assumptions about the degree to which improvements in adherence lead to health gains – although evidence <a href="http://www.nejm.org/doi/full/10.1056/NEJMra050100">suggests a clear link</a>. </p>
<p>The only way to provide a definitive answer to this question is to conduct a clinical trial. This is a potentially significant challenge that would require strong support from practices and service commissioners. Given patients frequently report irritation in the process of ordering regular medications, a trial would also offer the opportunity to compare and contrast the “customer” experience.</p>
<p>Until then, we must accept that the evidence does not support the current 28 day prescribing policy. The NHS needs to reconsider its approach – both to reduce costs and improve patient care.</p><img src="https://counter.theconversation.com/content/93522/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rupert Payne receives funding from the National Institute for Health Research. </span></em></p><p class="fine-print"><em><span>Céline Miani was involved in research projects funded by the National Institute for Health Research.</span></em></p>Current guidance is not leading to cost-effective practice.Rupert Payne, Consultant Senior Lecturer in Primary Health Care, University of BristolCéline Miani, Junior research group leader, Social epidemiology, Bielefeld UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/910982018-02-07T16:35:57Z2018-02-07T16:35:57ZWhy the annual winter health crisis could be solved in homes, not hospitals<figure><img src="https://images.theconversation.com/files/205271/original/file-20180207-74501-1iost9v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/queue-ambulances-outside-hospital-ae-department-586715234?src=WLUt0SeUSlGmoglO_wvNtA-1-0">Shutterstock</a></span></figcaption></figure><p>As winter continues, so does the usual soul searching about the state of the UK’s National Health Service (NHS). Images of ambulances backing up outside emergency departments and patients lying on trolleys in corridors haunt politicians and the public alike. </p>
<p>Demand on the NHS, which is always high, increases over the coldest of seasons, when threats to health are greatest. Generally, more than <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/excesswintermortalityinenglandandwales/previousReleases&ust=1517999520000000&usg=AFQjCNHFpZG1m7EhMlkj9AjAsbW2u3J9mg&hl=en&source=gmail">20,000 extra deaths</a> occur from December to March than in any other four-month period in England and Wales. That number varies considerably, however – from 17,460 in 2013-4 to 43,850 in 2014-5 (which was not even a particularly cold winter). And there has been no evidence of a decreasing trend since the early 1990s, despite the national flu immunisation programme. </p>
<p>The percentage increase in deaths seen each winter in England and Wales (21% last winter) <a href="https://academic.oup.com/eurpub/article/25/2/339/486080">is greater</a> than in many other European countries. Perhaps surprisingly, Scandinavia appears to fare better, while some Mediterranean countries fare worse. </p>
<p>Twenty years ago, the newly-elected Labour government introduced the <a href="https://www.gov.uk/government/collections/winter-fuel-payments-caseload-and-household-figures">system of winter fuel payments</a> for those of state pension age. Then, in 2000, the national flu immunisation programme was <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/635921/Inactivated_influenza_vaccine_information_for_healthcare_practitioners.pdf">extended to those aged over 65</a>. </p>
<p>While it is disappointing that the number of excess winter deaths has not decreased since these measures were introduced, it is perhaps remarkable that the numbers have not actually increased. Excess winter deaths particularly affect people aged over 65, and the number of such people in the UK increased between 2005 and 2015 by <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/articles/overviewoftheukpopulation/mar2017">at least 20%</a>. </p>
<p>In 2015, NICE, the body which recommends which treatments should be offered by the NHS, <a href="https://www.nice.org.uk/guidance/ng6">turned its attention</a> to the problem of excess winter deaths and illnesses. Their recommendations included a stipulation that people most vulnerable to cold weather needed to be identified. </p>
<p>But primary care professionals, especially GPs, have very little opportunity to visit people’s homes. So we wondered if patient records would help them to predict risk in cold weather for their older patients. </p>
<p>To identify those most vulnerable to cold weather, we linked regional daily temperatures to primary care data. But while it was clear that drops in temperature were generally followed by increased mortality, we could not clearly establish any single group of patients that were particularly affected – despite analysing an <a href="http://bjgp.org/content/early/2018/01/29/bjgp18X694829">enormous amount of data</a>. </p>
<p>We concluded that no simple method exists for GPs to identify patients most at risk when temperatures fall. So NICE’s recommendation may be unrealistic, chiming with scepticism <a href="http://www.bmj.com/content/350/bmj.h1183">expressed by some GPs at the time</a>. But if routine primary care records cannot help us, how do we go about identifying those most vulnerable to cold snaps? </p>
<p>To try and found out, we also conducted <a href="http://www.annalsofepidemiology.org/article/S1047-2797(17)30662-2/abstract">a survey</a> of men aged between 74 and 95 of whom a minority referred to difficulties heating the home in cold weather. These men – who were also more likely to perceive themselves as experiencing financial hardship and live in social isolation – had almost three times the risk of dying in the next two years. </p>
<p>Our results suggest that older people themselves are able to articulate their own vulnerability – and that care agencies could make better use of their clients’ own wisdom. </p>
<h2>Communication is key</h2>
<p>One of NICE’s recommendations suggested better systems of communication between primary health care and social care teams. Perhaps they could also make better use of the voluntary sector, which holds valuable information about people’s living conditions. Bristol’s <a href="https://www.cse.org.uk">Centre for Sustainable Energy</a>, for example, provides free advice on lowering energy bills, use of heating controls and installing home insulation. New systems to promote better communication between the care agencies are required, so that timely referrals can be made. </p>
<p>The pressures on the NHS caused by ill health in winter will require further innovations and research in communication and medicine. GPs will need more help in identifying those most at risk if we want to stop a winter health crisis from being an annual tradition. </p>
<p>But the search for those most vulnerable to cold weather and cold homes, fails to address the root problems. It has been <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)62114-0/abstract">shown across the world</a> that most deaths attributable to the cold occur on days when the weather is moderately – not severely – cold. This is because moderately cold days are far more common. And where do most people take shelter on moderately cold days? In their homes.</p>
<p>To decrease winter mortality and morbidity dramatically, we need to improve housing and insulation – and find more efficient and economic ways of heating homes. <a href="http://www.bris.ac.uk/social-community-medicine/people/richard-w-morris/publications.html">My involvement</a> in public health research has taught me that the greatest improvements in the health of a population are often achieved not by health care as such, but by interventions from other sectors of government. Dealing with the winter health crisis is no exception.</p>
<p>Progress is being made. Standards of new social housing have already <a href="https://www.housing.org.uk/blog/housing-association-homes-more-energy-efficient-more-accessible-and-better/">improved considerably</a>, to the extent that excess winter mortality is no worse among older people in modern social housing than in the rest of the older population. </p>
<p>But the private rental sector has generally fared worse – and a lack of regulation has left those on modest incomes particularly vulnerable. Improving the places where people actually live will improve their chances of surviving the winter – and help avert more seasonal crises.</p><img src="https://counter.theconversation.com/content/91098/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Morris has received funding from the National Institute for Health Research. </span></em></p>It’s the housing sector that could do most for winter health.Richard Morris, Professor in Medical Statistics, University of BristolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/892662017-12-18T14:58:14Z2017-12-18T14:58:14ZYes we must prescribe fewer antibiotics, but we’re ignoring the consequences<figure><img src="https://images.theconversation.com/files/199700/original/file-20171218-27538-12t0hgx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pills and ills. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/drug-prescription-treatment-medication-pharmaceutical-medicament-541252936?src=95CVAFs3xpmQn3gb0gGjlg-1-62">Adul10</a></span></figcaption></figure><p>Antibiotic resistance is one of the greatest challenges facing mankind. We <a href="http://www.who.int/antimicrobial-resistance/en/">risk a future</a> of common infections and minor injuries once again proving fatal – plus longer hospital stays and higher medical costs. Some infections are already no longer treatable with current drugs. <a href="https://amr-review.org">Around</a> 700,000 people die each year around the world as a result, and some studies predict 10m by 2050 – more than die from cancer. </p>
<p>To avoid this “<a href="https://www.theguardian.com/society/2017/oct/13/antibiotic-resistance-could-spell-end-of-modern-medicine-says-chief-medic">antibiotic apocalypse</a>”, everyone acknowledges we need to limit the quantities of antibiotics people are taking. One key strategy to achieve this is <a href="https://theconversation.com/we-need-more-than-just-new-antibiotics-to-fight-superbugs-44054">antimicrobial stewardship</a> – putting systems in place in hospitals and doctors’ surgeries that restrict antibiotic prescriptions by paying more attention to the type, timing, dosage and duration of courses of treatment. </p>
<p>With the UK currently close to completing a <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/244058/20130902_UK_5_year_AMR_strategy.pdf">five-year implementation plan</a> across the health service, and various <a href="http://www.who.int/hrh/news/2017/AMR2017-2.pdf">other countries also</a> at different stages of development, stewardship is undoubtedly proving <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003543.pub4/epdf">effective</a>. There is growing evidence that interventions by managers improve best practice and reduce the length of time that patients spend on antibiotics, <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003543.pub4/abstract">without increasing</a> mortality rates. </p>
<p>When <a href="https://academic.oup.com/jac/article-abstract/72/12/3223/4100561?redirectedFrom=fulltext">we analysed</a> the data, however, it became clear that there are also important lessons that need to be learned. The wider effects of stewardship are not well enough understood. The majority of studies into the effectiveness of tighter antibiotic restrictions have only focused on their intended outcome – cutting the quantities of drugs being prescribed. </p>
<p>Few studies have looked at other consequences, and sometimes these are not easy to predict. Even interventions that reduce the use of antibiotics can lead to unwelcome effects elsewhere in the system. </p>
<h2>Knowns and unknowns</h2>
<p>Since many consequences from tighter antibiotic restrictions are predictable, it’s important we start monitoring them from the outset. Measures commonly involve, for example, requiring frontline medics to get prior permission from a more senior colleague to make sure they’re prescribing the right antibiotic. </p>
<p>Another example is introducing stop orders, which end a course of treatment on a particular date if the clinician hasn’t specified one from the outset. Steps like these can interrupt or delay treatments, but we know little about to what extent. </p>
<p>Some restrictions will inevitably be too unwise to justify. When patients are showing symptoms of infectious pneumonia, for instance, it is common practice to start them on antibiotics before the diagnosis has been confirmed. People who turn out not to be infected will sometimes end up taking unnecessary antibiotics. But since the risks outweigh the benefits with this kind of potentially life-threatening condition, this is difficult to avoid. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/199701/original/file-20171218-27585-pkr8g6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/199701/original/file-20171218-27585-pkr8g6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/199701/original/file-20171218-27585-pkr8g6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/199701/original/file-20171218-27585-pkr8g6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/199701/original/file-20171218-27585-pkr8g6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/199701/original/file-20171218-27585-pkr8g6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/199701/original/file-20171218-27585-pkr8g6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/199701/original/file-20171218-27585-pkr8g6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Here’s the plan …</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/drug-prescription-treatment-medication-pharmaceutical-medicament-541252936?src=95CVAFs3xpmQn3gb0gGjlg-1-62">Rawpixel.com</a></span>
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<p>But if this kind of problem is foreseeable and needs to be exempted from any stewardship system, <a href="https://academic.oup.com/jac/article-abstract/72/12/3223/4100561?redirectedFrom=fulltext">our research</a> has also thrown up consequences that couldn’t have been anticipated. In 2009, for example, the Scottish government aimed to reduce by 30% over two years rates of the <em>Clostridium difficile</em> bug, which causes stomach pains, sickness and diarrhoea. This effort involved changing the type of antibiotic normally given to patients prior to various types of surgery to protect them from post-surgical infections. </p>
<p>One result was that more orthopaedic patients <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4214537/">ended up</a> developing acute kidney infections – ten more cases per month in one hospital. The managers setting up the stewardship system did not realise that stopping the antibiotic could lead to kidney infections in these patients. They ended up having to stay longer in hospital and needing more clinical interventions as a result. </p>
<p>Unexpected consequences can also be positive sometimes. One example is <a href="https://smw.ch/article/doi/smw.2014.13981">a study</a> of over 10,000 babies thought to be at risk of sepsis, a potentially deadly infection in the blood. The study looked at whether dispensing with the routine diagnostic blood test on these babies and relying only on other clinical examinations delayed the point at which you could start those testing positive for sepsis on a course of antibiotics. </p>
<p>If so, it would mean they would need more antibiotics for a longer duration and that the blood test was therefore a necessary means of controlling levels of prescriptions. Instead, however, the study confirmed that it made no difference, and in fact meant the infants could be given antibiotics earlier – so reducing the need for prescriptions. </p>
<h2>Pause for reflection</h2>
<p>This hopefully gives a glimpse into the complexity in this area, and the limitations in simply looking at cause and effect. <a href="https://siscc.dundee.ac.uk/work/improvement-science-methods/">As part</a> of our research, we have worked with practitioners around Scotland to understand how to monitor and predict consequences more effectively. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/199702/original/file-20171218-27538-1a2ybov.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/199702/original/file-20171218-27538-1a2ybov.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/199702/original/file-20171218-27538-1a2ybov.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=392&fit=crop&dpr=1 600w, https://images.theconversation.com/files/199702/original/file-20171218-27538-1a2ybov.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=392&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/199702/original/file-20171218-27538-1a2ybov.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=392&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/199702/original/file-20171218-27538-1a2ybov.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=493&fit=crop&dpr=1 754w, https://images.theconversation.com/files/199702/original/file-20171218-27538-1a2ybov.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=493&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/199702/original/file-20171218-27538-1a2ybov.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=493&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Until next time.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/patient-meeting-doctor-735167506?src=o5PGEE9iW88_z_4OqIXZXA-1-4">Rawpixel.com</a></span>
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<p>We’ve now produced a <a href="https://siscc.dundee.ac.uk/work/improvement-science-methods/">framework</a> to help managers to identify risks from the outset. It promotes the idea of an “improvement pause” to review the new system after a few months and make any necessary adjustments – hopefully making all the professionals involved more confident that the changes are benefiting patients and families. Unpleasant surprises in particular need to be carefully evaluated to see if any harm being caused is enough to stop or adapt the intervention.</p>
<p>The point is that to protect patients, all outcomes associated with changes to antibiotic prescriptions need to be monitored carefully. We’re not seeing nearly enough of this happening after systems are put in place. While interventions are vital to protect us all from antibiotic apocalypse, they still need to be balanced against the needs of patients today.</p><img src="https://counter.theconversation.com/content/89266/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Madalina Toma has received funding from the Economic and Social Research Council. </span></em></p><p class="fine-print"><em><span>Julie Anderson does not receive relevant direct funding but the SISCC receives funding from Scotland's Chief Scientist Office, Health Foundation, NHS Education for Scotland and Scottish Funding Council.</span></em></p>Antimicrobial stewardship is proving effective, but we’re not fully across what is happening.Madalina Toma, Research fellow, University of DundeeJulie Anderson, Associate Director, Scottish Improvement Science Collaborating Centre, University of DundeeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/805502017-07-11T07:08:06Z2017-07-11T07:08:06ZWhy GPs prescribe too many antibiotics and why it’s time to set targets<figure><img src="https://images.theconversation.com/files/177651/original/file-20170711-5923-1p0hli7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Our study suggests setting targets for antibiotic prescribing is the next step to curb their overuse.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/394817971?size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>Published yesterday, our <a href="https://www.mja.com.au/journal/2017/207/2/antibiotics-acute-respiratory-infections-general-practice-comparison-prescribing">study</a> estimates Australian GPs are prescribing about five million too many scripts for antibiotics a year for run-of-the-mill respiratory infections. But this is not a simple case of “blame the GP”.</p>
<p>What our study does show is <a href="https://www.nps.org.au/medical-info/clinical-topics/reducing-antibiotic-resistance">many years of educating GPs</a> about appropriate antibiotic prescribing, and the <a href="http://www.racgp.org.au/afp/2012/november/addressing-antibiotic-resistance/">link to antimicrobial resistance</a>, has failed to stem over-prescribing.</p>
<p>So, it’s time to set a national target for antibiotic prescribing in general practice, just like we set targets for carbon dioxide emissions to control the effects of climate change. Local <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/primary_health_networks">Primary Health Networks</a> could support GPs to meet these targets.</p>
<p>We’d also need to support GPs to easily and cheaply acquire the skills to help them reduce their prescribing safely. There are already <a href="http://www.racgp.org.au/publications/goodpractice/201611/antimicrobials-challenging-resistance/">moves towards</a> supporting GPs this way. However, we should be prepared for a slow and sustained effort.</p>
<p>If GPs can’t make these changes, they risk more draconian measures being imposed on them by government or bodies like the <a href="https://www.safetyandquality.gov.au/">Australian Commission on Safety and Quality in Health Care</a>. This might include GPs needing to seek an Authority Prescription from the Pharmaceutical Benefits Scheme to prescribe some antibiotics, and punitive measures being imposed on those prescribing beyond some arbitrary limits.</p>
<h2>What did we do and what did we find?</h2>
<p>We looked at the actual rates of antibiotic prescribing for acute respiratory infections, like sore throats, acute coughs (also called acute bronchitis), and acute middle ear infections. Our data was collected by a survey of about 500 GPs from across Australia, who recorded what they did in every consultation for two weeks. </p>
<p>We then compared that with the rate that would have occurred had every GP stuck rigidly to <a href="http://www.tg.org.au">Therapeutic Guidelines</a>, highly respected national prescribing guidelines many GPs use.</p>
<p>While we had expected about half of actual prescribing to meet the guidelines, we found just 11-23% met them. In national terms, that’s almost six million antibiotic prescriptions a year for these acute respiratory infections, compared with around one million a year had GPs stuck to the guidelines, a difference of roughly five million prescriptions a year.</p>
<h2>Why is this important?</h2>
<p>Each course of antibiotics contains roughly five grams of antibiotics. So, if GPs had stuck to the guidelines, we could safely reduce antibiotics use by 25 tonnes a year.</p>
<p>This mound of antibiotic represents an aspiration – what we could avoid, with minimal harm to the Australian public, and enormous benefits to reducing the generation of community acquired antibiotic resistance. </p>
<hr>
<p><em>Further reading: <a href="https://theconversation.com/we-know-why-bacteria-become-resistant-to-antibiotics-but-how-does-this-actually-happen-59891">We know why bacteria become resistant to antibiotics, but how does this actually happen?</a></em></p>
<hr>
<p>In the past we have not really had any target to aim for, but instead wondered if we should aim for the rates achieved by other countries such as the Netherlands (about half of our rates).</p>
<p>Our data show we could take that target much further.</p>
<h2>Why do GPs prescribe too many antibiotics?</h2>
<p>There are many reasons GPs prescribe too many antibiotics. GPs (and their patients) might want to minimise the risk of their patients being exposed to a dangerous bacterial infection that might have been avoided by prescribing antibiotics early. </p>
<p>Then there’s the diagnostic uncertainty that bedevils this part of primary care. Every apparently trivial cough or cold a GP sees could be the early stages of a dangerously serious infection, like community acquired <a href="https://www.healthdirect.gov.au/pneumonia">pneumonia</a>, <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/meningitis">meningitis</a>, or <a href="http://www.nhs.uk/conditions/Quinsy/Pages/Introduction.aspx">quinsy</a> (a complication of tonsilitis), and it is often very difficult to be sure in a single visit.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/177654/original/file-20170711-5989-qiab38.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/177654/original/file-20170711-5989-qiab38.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/177654/original/file-20170711-5989-qiab38.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/177654/original/file-20170711-5989-qiab38.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/177654/original/file-20170711-5989-qiab38.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/177654/original/file-20170711-5989-qiab38.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/177654/original/file-20170711-5989-qiab38.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/177654/original/file-20170711-5989-qiab38.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Symptoms of a run-of-the-mill respiratory infection could be the early stages of something more serious.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/367157885?src=2nRw70IgCX10BQ-O7tOz3g-1-3&size=medium_jpg">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Improving diagnosis might be possible using near-patient testing – a quick test in the surgery, rather than sending off a sample to a laboratory for testing. But these tests are only partly satisfactory because they are not always accurate enough, and they are very expensive, perhaps doubling the cost of the consultation.</p>
<p>Other important factors are:</p>
<ul>
<li><p>pressure from patients for GPs to prescribe antibiotics, either real or supposed by the GP. GPs often say this is a major influence, but <a href="http://www.annfammed.org/content/4/6/494.short">other studies</a> say it is often over-estimated by GPs</p></li>
<li><p>an assumption the consultation will be over quicker with a terminating prescription in time-poor general practice</p></li>
<li><p>commercial anxieties (“if I don’t give the patients what they’ve come for, they might go to other GPs more willing”)</p></li>
<li><p>habit (“why change what’s been working just fine 10 or 20 years ago if it isn’t broke?”), remembering that the consequences of antibiotic resistance happen in hospital care, far removed from this patient now </p></li>
<li><p>“failure of the commons”, in which a shared resource (in this case the absence of antibiotic resistance) is threatened by many individual interests (the individual is sick and wants whatever might quickest make them feel well again).</p></li>
</ul>
<h2>What needs to happen?</h2>
<p>It’s easy to jump to the conclusion from our findings that GPs should “stick to guidelines” when it comes to prescribing antibiotics. But that’s unrealistic. Guidelines are no more than their name suggests, simply a guide to how to manage a patient and their illness. </p>
<p>The real world is much more complicated: patients have additional illnesses, and other demands (often social, psychological or even just preference – for example, avoiding the risks of some symptoms even at the expense of some harms) – and the skillful GP needs to balance all this.</p>
<p>Our results, which demonstrate higher than expected rates of excess antibiotics prescribed, means we have a lot of antibiotic savings we could safely make.</p><img src="https://counter.theconversation.com/content/80550/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chris Del Mar has received funding from NHMRC, the Australian Commission for Safety and Quality in Healthcare, and from BUPA for work related to this topic. . </span></em></p>A study that shows GPs are prescribing about five million too many antibiotic scripts a year means we have to take a radical new approach to reducing use of these drugs.Chris Del Mar, Professor of Public Health, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/570352016-03-31T06:55:43Z2016-03-31T06:55:43ZTime for better chronic disease management in primary care<figure><img src="https://images.theconversation.com/files/116847/original/image-20160331-28476-1egothl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The government's proposed changes are good, and evidence based, but whether they will work in practice is another thing.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/downloading_tips.mhtml?code=&id=332819000&size=huge&image_format=jpg&method=download&super_url=http%3A%2F%2Fdownload.shutterstock.com%2Fgatekeeper%2FW3siZSI6MTQ1OTQxMjM4MCwiYyI6Il9waG90b19zZXNzaW9uX2lkIiwiZGMiOiJpZGxfMzMyODE5MDAwIiwiayI6InBob3RvLzMzMjgxOTAwMC9odWdlLmpwZyIsIm0iOiIxIiwiZCI6InNodXR0ZXJzdG9jay1tZWRpYSJ9LCJJK0NOcVp5ZFJRamI5TE1OTVovb0EwUWpoMHMiXQ%2Fshutterstock_332819000.jpg&racksite_id=ny&chosen_subscription=1&license=standard&src=7TRH99pC7A3yZxDSR-tvKg-1-2">from www.shutterstock.com.au</a></span></figcaption></figure><p>Living with a chronic disease, such as heart disease, diabetes or asthma, is hard work. Today the federal government <a href="http://www.abc.net.au/news/2016-03-31/turnbull-says-medicare-changes-will-help-health-system/7286474">announced</a> its intention to “<a href="http://sussanley.com/%EF%BB%BFa-healthier-medicare-for-chronically-ill-patients/">revolutionise</a>” the way chronic diseases and complex conditions are cared for. </p>
<p>Details are thin about what this health care revolution will look like. And while the early signs are promising, the task ahead is large.</p>
<p>The report of the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/primary-phcag-report">2015 Primary Health Care Advisory Group</a>, released today, includes recommendations to change the way health care is managed and funded. </p>
<p>Three key concepts seem to drive the recommendations – the need for continuity of care, flexible modes of delivery of health care and data to drive continuous quality improvement.</p>
<p>The key enablers to drive this reform are:</p>
<ul>
<li>patient registration (when a patient nominates a preferred practitioner and practice for care and attends there for health care)</li>
<li>multidisciplinary teams</li>
<li>data sharing between health care providers, planners and funders </li>
<li>a new funding mechanism (bundled payments rather than fee-for-service). </li>
</ul>
<p>All ideas are evidence-based and none are new. Evidence supporting these types of interventions has existed since the development of the <a href="http://content.healthaffairs.org/content/28/1/75.short">Chronic Care Model</a> in 1990s. </p>
<h2>How would the changes affect people with chronic conditions?</h2>
<p>If you are one of the 65,000 patients from one of the 200 practices that takes part in the proposed trial what can you expect? </p>
<p>Most probably you will have to agree to register with the practice for your chronic disease health care and agree to attend that practice for care. In return, you are likely to receive access to a multidisciplinary team and you will have more options about how you receive health care. </p>
<p>If all goes well, you would have fewer trips to the clinic, your conditions would be monitored more closely using more intelligent medical software systems and you would feel cared for, known about and healthy. </p>
<p>You would have access to good information about your health care conditions and you would always feel well informed. You would know that your health-care providers were also well informed.</p>
<p>When you needed care, you would get it. It might be via secure email, phone or web rather than face to face. And less time spent in waiting rooms. </p>
<p>If all this goes well – and the medications and lifestyle changes suit you, and you are well-supported and co-ordinated – chances are you will spend less time in hospital due to your chronic illness flaring up or complications developing. </p>
<h2>What gets in the way of achieving these outcomes?</h2>
<p>Some lessons can be learned from the 1994 <a href="https://www.mja.com.au/journal/2002/177/9/australian-coordinated-care-trials-success-or-failure">co-ordinated care trials</a>, which tested different models for co-ordinating care, and the more recent <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/eval-rep-dcp">diabetes care project</a>, which tested whether care plans, data-driven feedback, flexible funding and case management could lead to improved diabetes care. </p>
<p>The co-ordinated care trials showed some promise but were <a href="http://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/Publications_Archive/CIB/cib9899/99CIB11#Major">costly to implement</a> and too costly to scale up. They were difficult to replicate and few were sustained outside the trial environment. </p>
<p>The impact of the diabetes care project was also disappointing. The diabetes care project included many of the elements suggested in today’s report, such as bundled payments, yet only small gains were made in health outcomes and the cost-effectiveness of the model was not proven. The bundled payment used in the diabetes care project was viewed as inadequate. </p>
<p>Making improvements in chronic disease management is going to require strong buy-in from all stakeholders. The newly proposed model is the first step towards practices being held accountable for health-care outcomes. This must be done in a way that enhances rather than damages the patient-practitioner relationship.</p>
<p>One of the biggest challenges will be to work out exactly how much the government should pay a practice for providing a person with all their chronic disease care in a year. The report recommends that the payment should take into account complexity, using a three-tiered system. Addressing complexity is essential. It’s also where the whole concept could become unstuck. </p>
<p>GP payment is a another potential sticking point. Working out how an individual GP will get their fair share of the chronic disease payment is likely to make for interesting negotiations and new ways of working for practice managers. Female GPs will be vulnerable to further pay inequities as they are less likely to be practice owners and more likely to work part-time.</p>
<p>It is also not clear whether the recommended “bundled payment” would include more radical models whereby the practice has to fund payment for pathology, imaging and medications from the “bundled payment”. </p>
<p>The caveat that fee-for-service visits can be charged for episodic care unrelated to the chronic condition presents another challenge. While it makes sense that not all care is related to a chronic condition, allowing fee-for-service payments alongside the bundled payment reduces the likely cost-effectiveness of any proposed model. This is especially so if this is done in a way that requires administrative and clinical time to be spent deciding whether it is an “unrelated” condition, or not. </p>
<p>It will be a challenge to get eligible practices and patients to sign on to the trial. This took much time and effort in the co-ordinated care trials and the diabetes care project. There will need to be very clear messaging that engages practices and consumers and explains just what they stand to gain (and lose) from the proposed changes. <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/primary_health_networks">Primary Health Networks</a>, regional bodies that coordinate care, should be able to play a key role here. </p>
<p>It will be important to recognise the diversity of practices and the regional differences. Ensuring new payment models reduce inequity will require careful use of weightings to adequately reward the practices caring for disadvantaged groups. </p>
<p>The final challenge will be around the use of routinely collected clinical data to monitor health outcomes. Using clinical data to develop the prediction tools and real-time clinical decision support alluded to in the report will require ongoing investment in the expertise and IT infrastructure required to do this work. </p>
<p>The Australian health care system is currently served by multiple clinical software systems across the primary care and hospital sectors. At present it is difficult to link the data to make sense of the entire patient journey. </p>
<p>Health care should make life easier, not harder. The proposed reforms are promising and long overdue. They will be challenging to implement but the time has come to do so.</p><img src="https://counter.theconversation.com/content/57035/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jane Gunn receives funding from the National Health and Medical Research Council for trials of new models of care for depression and diabetes. She is on the Board of Eastern Melbourne PHN. She is a member of the National Prescribing Service Data Governance Advisory Committee.</span></em></p>Living with a chronic disease is hard work. Today the federal government announced its intention to “revolutionise” the way chronic diseases and complex conditions are cared for.Jane Gunn, Head of Department of General Practice, Chair of Primary Care Research, Deputy Head, Melbourne Medical School, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/455922015-08-11T20:34:35Z2015-08-11T20:34:35ZActing on family violence: how the health system can step up<figure><img src="https://images.theconversation.com/files/91261/original/image-20150810-11097-txayp8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It's estimated general practitioners see up to five abused women every week.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/ajay13/8788680283/in/photolist-eoChsp-j4Z16k-L7GYi-9s3iZm-atPGkx-91EVdy-ppoGu2-vP8SaY-cxm8dJ-n9Ex3z-7UHyig-kVkx24-9szkWh-6tkNag-7Q2htb-Bdzqn-r7c2Xo-cip6fS-ajqBBq-a1vpRx-5TxxkF-gyZCy1-b6ixja-uU64KP-nsJmh2-vWqf47-kx9i3B-6UMsE7-">Aikawa Ke/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>The health system has a vital role in ensuring doctors and nurses provide an appropriate, first-line response to victims of family violence. But it’s lagging behind. Today, I’ll be telling the <a href="http://www.rcfv.com.au/Public-Hearings">Victorian Government’s Royal Commission into Family Violence</a> how the health system can step up to the challenge.</p>
<p>At least <a href="http://www.rcfv.com.au/getattachment/6442E593-04E1-4C3D-839E-AEFFD15D00CC/Melbourne-Research-Alliance-to-End-Violence-Against-Women-and-Their-Children">80% of women</a> experiencing abuse seek help from health services, usually general practice. It’s <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1467-842X.2002.tb00344.x/abstract">estimated</a> a general practitioner sees up to five abused women weekly who <a href="http://apps.who.int/iris/bitstream/10665/85241/1/WHO_RHR_HRP_13.06_eng.pdf?ua=1">present with symptoms</a> of violence in the home. Some patients suffer depression, anxiety and long-term headaches. For others, the stress of abuse can lead to premature labour or even miscarriage. Doctors treat the symptoms and often don’t ask about the cause; women sometimes don’t tell.</p>
<p>There are currently <a href="http://www.racgp.org.au/your-practice/guidelines/whitebook/">excellent guidelines</a> some health professionals follow, but others don’t. This isn’t enough. Health professionals need compulsory training to ensure better health and safety outcomes for women and children experiencing domestic violence. Only an organisational shift can make this happen. Practitioners need a supportive environment and changes in health system protocols and polices. </p>
<p>It should be noted that many of the studies in this area are based on women, as they are the <a href="https://theconversation.com/to-change-attitudes-to-family-violence-we-need-a-shift-in-gender-views-44718">main victims</a> of severe physical and sexual abuse. But the same principles apply to male victims.</p>
<h2>Removing barriers</h2>
<p>Women face many <a href="http://www.ncbi.nlm.nih.gov/pubmed/21160053">barriers</a> to discussing family violence with professionals. They include shame, worries about being judged or disbelieved, and confidentiality concerns. Many doctors have had <a href="http://metatoc.com/papers/46353-are-future-doctors-taught-to-respond-to-intimate-partner-violence-a-study-of-australian-medical-schools">minimal to no training</a> in dealing with the effects of partner violence. Some don’t have the time to respond adequately if a patient discloses their experience.</p>
<p>Policymakers and researchers have suggested <a href="http://www.cochrane.org/CD007007/BEHAV_screening-women-intimate-partner-violence-healthcare-settings">screening</a> (asking all women attending a clinic or hospital a standard set of questions) to overcome these barriers and help doctors and nurses identify patients experiencing family violence. </p>
<p>Screening may sound like a good idea but many practitioners are <a href="https://theconversation.com/midwives-can-help-detect-domestic-violence-heres-how-37918">reluctant</a> to use it. They might feel overwhelmed by the emotional task of responding to disclosures. Further, health professionals sometimes have their <a href="http://www.stfm.org/FamilyMedicine/Vol44Issue6/Candib416">own experience</a> of family violence which, if recent, might hinder their willingness to bring it up with patients.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/91281/original/image-20150810-11097-1vxg8qq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/91281/original/image-20150810-11097-1vxg8qq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/91281/original/image-20150810-11097-1vxg8qq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/91281/original/image-20150810-11097-1vxg8qq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/91281/original/image-20150810-11097-1vxg8qq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/91281/original/image-20150810-11097-1vxg8qq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/91281/original/image-20150810-11097-1vxg8qq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Women face many barriers to discussing family violence with professionals.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Although screening helps identify some women experiencing domestic violence, the numbers are still lower than expected. Screening also doesn’t increase referrals to specialist services or improve women’s health outcomes. A US <a href="http://jama.jamanetwork.com/article.aspx?articleid=2422536&linkId=15934037">study</a> released last week showed no long-term health benefits to women who were screened and provided with a partner violence resource list. </p>
<p>The <a href="http://www.who.int/reproductivehealth/publications/violence/9789241548595/en/">World Health Organisation</a> doesn’t recommend screening in health settings unless the woman is pregnant. A <a href="http://www.cochrane.org/CD007007/BEHAV_screening-women-intimate-partner-violence-healthcare-settings">global review</a> of more than a dozen studies has backed up this advice. It concludes the small amount of existing evidence shows identification increases but has little benefit to women. </p>
<h2>Training professionals</h2>
<p>The lack of evidence for screening doesn’t mean doctors and nurses shouldn’t use <a href="http://www.addictioneducation.co.uk/BMJ%20article%202008.pdf">prompting questions</a> to investigate whether family violence is present when women and children show recognised symptoms. If patients <a href="http://www.pec-journal.com/article/S0738-3991(13)00311-X/pdf">feel ready</a> to disclose abuse, health professionals should show <a href="http://www.who.int/reproductivehealth/publications/violence/9789241548595/en">empathy</a> and follow up with <a href="http://www.dhs.vic.gov.au/about-the-department/documents-and-resources/policies,-guidelines-and-legislation/family-violence-risk-assessment-risk-management-framework-manual">safety questions</a>. Women <a href="http://apps.who.int/iris/bitstream/10665/136101/1/WHO_RHR_14.26_eng.pdf?ua=1">should be</a> listened to, believed, asked about their needs, have their risk and safety assessed and be offered ongoing support.</p>
<p>Some women are ready for referrals at the point of disclosure. For the many who aren’t, studies have suggested family doctors be trained to provide supportive counselling. This <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60052-5/fulltext">has been shown</a> to reduce depressive symptoms in women experiencing abuse. </p>
<p>Advocacy is also beneficial. This is where appropriately trained <a href="http://www.researchgate.net/publication/7658230_A_randomized_controlled_trial_of_empowerment_training_for_Chinese_abused_women_in_Hong_Kong">health-care providers</a> or specialist family violence services give women information and psychological support to access community resources. Survivors can be linked with legal, police, housing and financial services. Advocacy and support intervention <a href="http://www.cochrane.org/CD005043/BEHAV_advocacy-interventions-to-help-women-who-experience-intimate-partner-abuse">trials</a> for women who have sought help from shelters report reductions in violence and improvements in mental health. </p>
<p>For training to be effective, it must be provided as part of university courses and throughout a practitioner’s career. Health professionals usually respond best when they are trained by a peer. Effective training also involves role-playing asking and responding with actors, reflections on personal attitudes towards violence against women, hearing survivor stories and reviewing patients’ files.</p>
<p>While doctors’ and nurses’ ability to respond appropriately when they suspect family violence is vital, it can only work if the broader <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61837-7/fulltext">health system</a> is supportive of women-centred care.</p>
<h2>Health system response</h2>
<p>A whole-of-system response involves an appropriate, sensitive environment for <a href="http://www.asca.org.au/Home.aspx">traumatised people</a>, <a href="https://www.thewomens.org.au/news/dr-sue-matthews-opinion-in-the-age/">strong management support</a> for the importance of the work, and practitioner support and mentoring. In the <a href="https://xnet.kp.org/domesticviolence/about/index.html">United States</a>, some of these system changes have led to a dramatic increase in numbers identified. </p>
<p>Governments should create policies to facilitate referral pathways for health professionals, both internally and externally, with community services. Policies should also ensure data collection and information-sharing between agencies. Health settings can create supportive environments with leaflets and posters promoting awareness about family violence consultations and referrals.</p>
<p>The Commonwealth government could add Medicare item numbers for general practitioners, psychiatrists, psychologists and social workers (with family violence training) – similar to the current <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-ba-fact-pat">mental health care plans</a> – to undertake safety planning. These would allow for longer, half-an-hour sessions.</p>
<p>State governments can:</p>
<ul>
<li>Allocate funding for regional health services to have family violence coordinators and for every hospital to have a clinical professional implement organisational change.</li>
<li>Allocate finances to overstretched family violence services for women, children and men.</li>
<li> Fund trauma-informed counselling for <a href="http://www.berrystreet.org.au/Assets/1252/1/Turtleprogrambrochure.pdf">mothers and children</a>, as <a href="http://www.who.int/reproductivehealth/publications/violence/9789241548595/en">recommended</a> by the World Health Organization. This would help fill Australia’s chasm of referral options, particularly for women and children who have left the relationship.</li>
</ul>
<p>Finally, we must ensure the health recommendations heard at the Royal Commission today lead to practical outcomes. If health professionals continue to only treat symptoms of family violence, the cycle of women’s physical and mental deterioration and damage to children will continue.</p><img src="https://counter.theconversation.com/content/45592/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kelsey Hegarty received funding from NHMRC for the weave trial. She has been a Temporary Clinical Advisor for the WHO and an author on the Cochrane Clinical Reviews.</span></em></p>Victoria’s Royal Commission into Family Violence will today hear how the health system can better respond to partner abuse, with the help of trained professionals and broader, government support.Kelsey Hegarty, Professor, Department of General Practice; Director of Researching Abuse and Violence in Primary Care program; Director of Post graduate Primary Care Nursing, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/456502015-08-06T04:45:30Z2015-08-06T04:45:30ZWhat’s normal, anyway? GPs should discourage women from unnecessary genital surgery<figure><img src="https://images.theconversation.com/files/90969/original/image-20150806-1969-1c47b0z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women are increasingly feeling embarrassed about their genital appearance.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/sophielovescute/4660990790/in/photolist-6mcyHt-7ZBJTA-6qgCYn-4K7LN3-86SNbb-7um8th-bEdZ6h-7jq1Nu-avokom-9PWDbR-58hvVT-7mq5Ex-fmM8c-nuPunk-nuPJf1-nM9fAm-nARVnZ-bUDgfr-runCRE-o6s6R7-nR1hy7-o8n94E-s9VFUB-bRRzL4-5v6X2B-dcCTRt-7fhPi2-isqYLk-kgdr3T-kgf8py-kgfcAj-avoto1-nuQcUg-nuPJw3-e5DY5p-pSGTox-oagEnp-o8n9i7-o8n913-7ftXHv-aNwLZK-7VZ6CD-rBYWf-7fhPiP-7TdEKU-9P7mwH-sfiWxa-ehTFHM-dsSiTH-6SGnjz">Sophie/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>General practitioners have an important role to play in alleviating women’s anxiety about their genital appearance and can help stop the rise in women going under the knife for cosmetic reasons.</p>
<p><a href="http://whv.org.au/static/files/assets/ca7e9b2f/Women-and-genital-cosmetic-surgery-issues-paper.pdf">Figures show</a> 640 Australian women made Medicare claims for genital cosmetic surgery in 2000. The number grew threefold over the next decade, with 1,565 claiming the same surgeries on Medicare in 2011. There was no accompanying rise in the incidence of congenital or acquired diseases that would need such surgery.</p>
<p>The Medicare statistics reveal surgeries are as common among women between the ages of 15 to 24 as they are among those between 25 to 44. These figures are only the tip of iceberg as most women seek out genital cosmetic surgery through the non-rebatable, private system.</p>
<p>In response, the Royal Australian College of General Practitioners this week <a href="http://www.abc.net.au/news/2015-08-03/world-first-guidelines-for-female-genital-surgery-requests/6669306">introduced</a> world-first guidelines to advise doctors how best to deal with women’s rising interest in having genital cosmetic surgery.</p>
<p>When women ask for surgical modification to their genital tissue, they often don’t know enough to describe what they want removed, nor do many understand the long-term implications. </p>
<h2>What is normal?</h2>
<p>As a GP with more than 20 years’ experience in women’s health, I have seen a marked increase in the number of women embarrassed about their genital appearance. They might hint at their shame during a routine gynaecological procedure, either as an apology for how they look “down there” or as a blatant statement such as: “It’s so ugly, I’m so embarrassed, I want it fixed.” </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/90864/original/image-20150805-22449-14zgnro.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/90864/original/image-20150805-22449-14zgnro.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=359&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90864/original/image-20150805-22449-14zgnro.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=359&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90864/original/image-20150805-22449-14zgnro.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=359&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90864/original/image-20150805-22449-14zgnro.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=451&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90864/original/image-20150805-22449-14zgnro.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=451&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90864/original/image-20150805-22449-14zgnro.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=451&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">General practitioners are often the first medical professional to see a woman’s anxiety over her genital appearance.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/cane_rosso/2124744542/in/photolist-4eKSwA-aDDLUg-xNiWs-6wUHts-6wdZBD-bGCLJH-N6K2x-6SyALq-9p25xE-bPzRSZ-712Nbm-N6Kq6-J1G5Q-bndKvQ-8UMM2s-axeTfZ-baTtMe-2TQPPY-3MwcX-4uJwjV-5ES6ez-7aZeQT-5qy5Mo-eLg8N-kN5eGt-9SFC43-4PU8VU-9mtgE4-9mnUG5-7vMD8T-bvU3Se-xpQdo-biJpoZ-9y5ues-8FyXXg-9SCDiT-aCE5xn-5HbsX2-kN6S6g-kN7RFs-kN5Gga-kN5r96-kN7nzN-kN7ajq-kN54Rr-kN72iq-kN4T68-kN6LF9-kN6zsN-kN4r3M">Ludo/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>General practitioners are often the first medical professional to see a woman’s anxiety over her genital appearance. This embarrassment may be based on an idealised benchmark of stylised, hairless and prepubescent genitals, so often depicted and promulgated through media, pornography and fashion. In real life, though, women and men know very little about genital diversity. And little research has been conducted on what constitutes normal genital appearance.</p>
<p>Marketers of female genital cosmetic surgery make a genital tissue “trim” seem like a simple lifestyle choice. But trimming labia is not the same as trimming one’s hair. The labia minora (inner lips) isn’t made of ordinary skin but tissue rich with nerve fibres <a href="http://www.ncbi.nlm.nih.gov/pubmed/18564153">that developed</a> as part of the primordial phallus (what becomes the clitoris during fetal development). </p>
<h2>A lucrative industry</h2>
<p>Female genital cosmetic surgery comprises a suite of relatively new procedures. Labiaplasty – where the labia minora are “trimmed” to not extend beyond the margins of the labia majora (outer lips) – is the most common, accounting for about 50% of all such surgeries. </p>
<p>Genital-related anxiety seems to have increased over the past decade, along with the use of <a href="https://www.themedicalbag.com/bodymodstory/porn-star-surgeryaka-the-barbie">terms</a> such as “Barbie-plasty”, “designer vagina” and “vaginal rejuvenation”. Google these and you see a plethora of consumer websites touting “facts” <a href="http://www.aesthetica.com.au/treatments/labiaplasty/">such as</a>: “more than 30% of women have excess genital tissue”. </p>
<p>These websites reinforce existing social and cultural messages about the vulva and vagina but <a href="http://bmjopen.bmj.com/content/2/6/e001908.full">offer scant information</a> about the diversity of genital appearance. Nor do they talk about the long-term risks of the surgery, which have not yet been researched. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/90863/original/image-20150805-22481-hy1wo.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/90863/original/image-20150805-22481-hy1wo.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/90863/original/image-20150805-22481-hy1wo.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=789&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90863/original/image-20150805-22481-hy1wo.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=789&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90863/original/image-20150805-22481-hy1wo.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=789&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90863/original/image-20150805-22481-hy1wo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=991&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90863/original/image-20150805-22481-hy1wo.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=991&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90863/original/image-20150805-22481-hy1wo.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=991&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">In female genital cosmetic surgery, the labia minora are ‘trimmed’ to not extend beyond the margins of the labia majora.</span>
<span class="attribution"><a class="source" href="http://www.labialibrary.org.au/anatomy/">The Labia Library/Women's Health Victoria</a>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Such advertisements tap into the dissatisfaction some women feel about not being “normal”. But their existence shows a new and lucrative area. Prices in Australia for labiaplasty vary from A$3,000 to A$9,000 and can be coupled with clitoral hood reduction or mons pubis reduction (the mounded area above the pubic bone) – specialties women are seeking in high numbers. </p>
<p>These surgeries can be performed by anyone with a medical degree. No formal training is required and there are currently no evidence-based guidelines to support the procedures.</p>
<p>Complications often arise. Surgeons may remove too much genital tissue, exposing the woman’s clitoral head to undergarments and causing pain in ordinary clothing. Another common complication is irregularity and scarring along the trimmed labia minora or change in pigmentation of the skin and hypersensitivity. </p>
<p>Worryingly, the complications are so common that one prominent, plastic surgeon in the United States has found a lucrative market for correcting them, dubbing them <a href="http://www.labiaplastyrevisionsurgeon.com/index.html">“botched labiaplasties”</a>.</p>
<h2>Guidelines for GPs</h2>
<p>While few Australian researchers have explored the GPs’ role in cosmetic surgery, UK studies <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3020045/">have indicated</a> a need for GPs to educate women who express concern about their genital normality or appearance.</p>
<p>The recently launched doctors’ resource – the <a href="http://www.racgp.org.au/your-practice/guidelines/female-genital-cosmetic-surgery/">RACGP guidelines</a> for female genital cosmetic surgery, which I helped develop – address the lack of balanced information. The guidelines recommend doctors listen to and educate patients about genital normality. Doctors are encouraged to refer women to sites such as the <a href="http://www.labialibrary.org.au">Labia Library</a> to help them understand the diversity of genital appearance.</p>
<p>Guidelines also advise GPs to examine the woman respectfully and explore the reasons for her concern. This is an opportunity to consider the psychological or sexual reasons for her anxiety by discussing personal or relationship issues, past history of sexual abuse or even mental health issues. Anecdotal evidence from GPs and surgeons suggests coercion due to partner criticism is sometimes a factor for women’s genital shame.</p>
<p>GPs should refer a woman for a gynaecological opinion if they feel their advice is not sufficiently reassuring. If the patient is under 18, they should refer her to an expert adolescent gynaecologist. </p>
<p>Hopefully the RACGP guide will prompt GPs and other health professionals to take the time to discuss women’s concerns about their genital appearance and ultimately reduce the rate of unnecessary and potentially harmful surgery.</p><img src="https://counter.theconversation.com/content/45650/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Magdalena Simonis is affiliated with
RACGP National standing Committee Quality Care
Women's Health Victoria, board member .</span></em></p>New guidelines launched by the Royal Australian College of General Practitioners aim to help doctors educate women about the variety of genital appearance and stop them having unnecessary surgery.Magdalena Simonis, Lecturer, General Practice and Primary Health Care Academic Centre, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/449082015-07-24T04:03:42Z2015-07-24T04:03:42ZWhat you should expect from your GP<figure><img src="https://images.theconversation.com/files/89454/original/image-20150723-22826-fkmg3w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The major impediment to realising the ideal of good general practice is that few patients understand it.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/proimos/6870109454/">Alex Proimos/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>Australia spent <a href="http://www.myhealthycommunities.gov.au/Content/publications/downloads/NHPA_HC_Frequent_GP_attenders_Media_Release_March_2015.pdf">$16 billion on GP-related health care in 2012-13</a>. That’s about $690 for each person. Given that our public health system means each of us is paying for health care through our taxes, what should we expect from our doctors?</p>
<p>Generally, Australians expect ready access to a general practitioner when they’re ill, and they want a GP who will listen carefully to what they say. But there are many other services you should expect.</p>
<p>These include: dealing with ongoing problems; anticipating and preventing diseases you’re at risk of developing; promoting good health generally and providing appropriate health education to this end; helping you get the most out of all health-care professions when you’re ill; doing house calls when necessary; being compassionate and knowledgeable about the process of death and dying; and generally being your health advocate.</p>
<h2>Empowering patients</h2>
<p>One measure of a good GP is when she takes two minutes to diagnose your sore throat and then says, “Good, we now have ten minutes of the consultation left to examine you for skin cancers, review your asthma and answer any questions you have about your health.”</p>
<p>This preventive medicine approach aims to stop or detect the earliest evidence of disease and deal with it. At the very least, your GP should ensure that you know your blood group, blood pressure and cholesterol levels, and your family’s history of important disorders, such as heart attacks, diabetes, aortic aneurysm, glaucoma and certain types of cancers. Being aware of these risks means you’re likely to detect abnormalities earlier and get them treated.</p>
<p>Your GP should also teach you how to get the best from the health system. This includes knowing when you shouldn’t bother seeing a doctor. You should probably avoid your local GP when you have a cold, for instance, but not put off a consultation for new, severe symptoms until Friday evening. </p>
<p>The former will just help spread the virus causing the cold throughout your doctor’s waiting room. The latter will result in referral to a hospital emergency department since the necessary community-based investigative facilities will be closed.</p>
<p>At some stage, you’re going to be too ill or too infectious to get to your local doctor’s surgery. You should expect that your GP will make a house call when that happens. </p>
<p>House visits are time-consuming and uneconomic for doctors. But they’re useful because they give her unique insights into your interpersonal relationships, financial circumstances and lifestyle. These insights will give her a better view of how you’re really coping.</p>
<h2>That extra little bit</h2>
<p>You never know when you’ll get really unwell out of the usual surgery hours. So your GP should ensure you know what sort of medical help is available to you and how to access it.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/89594/original/image-20150724-20950-1c8t2m.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/89594/original/image-20150724-20950-1c8t2m.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=388&fit=crop&dpr=1 600w, https://images.theconversation.com/files/89594/original/image-20150724-20950-1c8t2m.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=388&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/89594/original/image-20150724-20950-1c8t2m.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=388&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/89594/original/image-20150724-20950-1c8t2m.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=487&fit=crop&dpr=1 754w, https://images.theconversation.com/files/89594/original/image-20150724-20950-1c8t2m.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=487&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/89594/original/image-20150724-20950-1c8t2m.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=487&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">You should expect more than episodic care for a series of acute illnesses from your general practitioner.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/zunami/4352535111/">Claus Rebler/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>She should have good records that contain a summary of your current and pertinent past problems. Until the personally controlled electronic health record (PCEHR) system is working, you should have several copies of this summary. You can take it to any after-hours medical service you visit, or use it when you’re travelling. It will save you a lot of time, medical investigation and money.</p>
<p>A common cause for a patient suing her doctor is for her failure to diagnose a serious condition. But patients who go from doctor to doctor so that no single health professional ever has the opportunity of seeing their changing symptoms and signs put themselves in diagnostic jeopardy. </p>
<p>Medicare provides for the preparation of various health management plans. Used properly by a patient’s regular GP, they’re useful. But beware of other practices, which you don’t regularly visit, that want to maximise their income by doing a health management plan for you. </p>
<p>Finally, your GP should be your health advocate. The modern health system is complex and patients can get lost in it. They can also get lost on hospital waiting lists. The advocacy of your GP can often work a bureaucratic miracle.</p>
<h2>Endangering the species</h2>
<p>Sounds positively utopian, doesn’t it? But the problem is you. The major impediment to realising this ideal of good general practice is that few patients understand the task of general practice and the part that GPs could and should play in their health care. </p>
<p>Indeed, many health-care consumers place convenience above quality. They attend any clinic where “there’s no waiting, they give you what you want and you don’t have to pay”. </p>
<p>But these same patients go and see their old family doctor when they’re really sick or worried. Sadly, they seem unaware that their consulting behaviour renders their family GP a financially endangered species.</p>
<p>Now that you know what you should expect, I hope you will become a more discerning and demanding consumer of health care, who expects more from your GP than quick, bulk-billed, episodic care for a series of acute illnesses. </p>
<p>If you expect a lot, a lot is what you may get. It may mean that your local parliamentary member starts listening to your expectations, and the federal government stops destroying quality general practice.</p><img src="https://counter.theconversation.com/content/44908/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Max Kamien was the Foundation Professor of General Practice at the University of Western Australia. He now is the Provost and Corlis Fellow of the Western Australian Faculty of the Royal Australian College of General Practitioners and a part-time remote area locum GP.
He has been trying to improve patients' expectations of their GP for several decades, including during an appearance on Ockham's Razor on 18/3/2001.</span></em></p>Australia spent $16 billion on GP-related health care in 2012-13. Given that our public health system means each of us is paying for health care through our taxes, what should we expect from doctors?Max Kamien, Emeritus Professor of General Practice & Corlis Fellow of the RACGP, The University of Western AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/387862015-03-22T19:15:06Z2015-03-22T19:15:06ZHigh cost of GP rebate freeze may see co-payments rise from the dead<figure><img src="https://images.theconversation.com/files/75036/original/image-20150317-9211-yoxy6l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">New modelling shows the Medicare rebate freeze will leave GPs A$8.43 worse off per consultation</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/diacimages/5774894486">DIBP images/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Prime Minister Tony Abbott has <a href="http://www.smh.com.au/federal-politics/political-news/gp-copayment-fee-is-dead-buried-and-cremated-tony-abbott-20150303-13u3ec.html">declared</a> that GP co-payments are “dead, buried and cremated”. This contrasts with health minister Sussan Ley’s <a href="http://www.skynews.com.au/news/politics/national/2015/03/04/ley-rules-out-means-testing-bulk-billing.html">desire</a> to “reduce the number of bulk-billed consultations to people who can afford to pay something”. </p>
<p>So, what is likely to emerge from Ley’s Medicare reform consultations? </p>
<p>In a paper published today in the <a href="https://www.mja.com.au/journal/2015/202/6/cost-freezing-general-practice">Medical Journal of Australia</a>, our new modelling shows the freeze on Medicare fees paid to GPs will leave doctors A$8.43 worse off per consultation with non-concessional patients by 2017-18. That’s a bigger shortfall than the now-abandoned A$5 rebate cut – and is likely to prompt many GPs to start charging a co-payment. </p>
<p>Currently, legislative restraints mean that GPs are only able to charge the government directly for patient care (bulk-billing) if they do not charge the patient a co-payment.</p>
<p>However, Ley has suggested that the government would consider legislative change that would <a href="http://www.news.com.au/lifestyle/health/lazarus-or-zombie-the-gp-fee-is-rising-from-the-dead/story-fneuz9ev-1227248137618">remove this restriction</a>. This would mean that GPs could bulk-bill the scheduled fee and also charge a co-payment. </p>
<p>With GPs facing greater economic pressure and the health minister considering legislative changes to make it easier for GP to charge them, GP co-payments, like Lazarus, may rise again from the dead.</p>
<h2>First, a quick recap</h2>
<p>The first of the recent co-payment policies was revealed in the 2014-15 Federal budget. It proposed a A$7 patient co-payment for GP, pathology and imaging services to offset a A$5 reduction in the associated Medicare rebates. The financial impact of the original co-payment proposals was <a href="https://theconversation.com/co-payment-will-hit-harder-than-expected-sydney-university-study-finds-28871">greatest</a> for Commonwealth Concession card patients.</p>
<p>Facing strong opposition, the government withdrew the A$7 co-payment policy in December 2014, and replaced it with three new policies. The first, a ten-minute minimum for standard GP consultations (the “A$20 co-payment”) was retracted in January. </p>
<p>The second, a A$5 reduction in the Medicare rebate for “common GP consultations” for non-concessional patients was retracted in March. It was this retraction that led Prime Minister Abbott to state co-payments were “dead, buried and cremated”.</p>
<p>However, the third policy announced in December remains on the table. It is a continuation of the indexation freeze for all Medicare schedule fees until July 2018. While not a direct cut to GPs’ income, over time GPs would earn relatively less while their costs would increase. </p>
<h2>The cost of the ‘freeze’</h2>
<p>In our modelling for MJA, we used data from the University of Sydney’s <a href="ses.library.usyd.edu.au/bitstream/2123/11882/4/9781743324226_ONLINE.pdf">Bettering the Evaluation and Care of Health</a> (BEACH) study to estimate the amount of rebate claimable through Medicare per 100 GP consultations. BEACH is a continuous cross-sectional, national study of the content of GP-patient encounters in Australia.</p>
<p>More than half (54.4%) of GP consultations were with concessional patients (those under 16 years of age or those holding a health care card) while 45.6% were with non-concessional patients.</p>
<p>We calculated that in 2014-15, an average bulk-billing GP would earn A$4,998.28 from Medicare rebates per 100 consultations. </p>
<p>For GPs to maintain rebate income equivalent to 2014-15, the Medicare scheduled fees would have to increase in line with CPI. So assuming an annual CPI increase of 2.5%, by 2017-18 these fees would need to increase by 7.7% – A$384.32 per 100 consultations. </p>
<p>By freezing fees until 2017-18, the government is cutting the GPs’ gross earnings by 7.1% in relative terms. Assuming concessional patients are all bulk-billed, this A$384.32 decrease equates to A$8.43 per non-concessional patient consultation.</p>
<p>In comparison, the (now retracted) A$5 reduction in rebate for most consultations with non-concessional patients would have amounted to a loss of A$219.53 per 100 consultations, or A$4.81 per consultation with a non-concessional patient.</p>
<p><br></p>
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<h2>Making up the shortfall</h2>
<p>While public discussion has focused on the now retracted A$5 reduction, the freeze will have a greater impact: A$8.43 per non-concessional patient consultation by 2017-18, nearly double the amount of the rebate reduction. </p>
<p>The 7.1% reduction in GP rebate income by 2017-18 from the freeze may economically force GPs who currently bulk-bill to charge a co-payment to their non-concessional patients. As Grattan Institute health economist Professor Stephen Duckett <a href="http://www.abc.net.au/news/2015-03-05/duckett-we-still-have-a-gp-co-payment-by-stealth/6282094">notes</a>, this is a “co-payment policy by stealth”.</p>
<p>Our estimates are conservative. The A$8.43 figure would be the minimum charge needed to make up for the GPs lost income. We did not account for: administrative costs in implementing new billing systems; increased bad debt; the previous freeze of fees; and lost income when a GP chooses to bulk-bill non-concessional patients facing financial hardship. </p>
<p>It is therefore likely that GPs who opt to charge a co-payment, will charge more than our estimates. Further, after abandoning bulk-billing, some GPs may take the opportunity to charge more than that required to merely recoup their rebate loss. </p>
<p>Statements by health minister Ley and the ongoing effect of the index freeze suggest we’re likely to see GP co-payments in the near future.</p><img src="https://counter.theconversation.com/content/38786/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher Harrison is a Greens volunteer.</span></em></p><p class="fine-print"><em><span>Graeme Miller is co-chief investigator of the BEACH program. In 2013-14 BEACH was funded by a competitive grant from the Commonwealth Department of Health, and through University of Sydney research agreements with Astra Zeneca Pty Ltd, Novaritis Pharmaceuticals Australia Ptry ltd, and CSL Biotherapies Pty Ltd.</span></em></p><p class="fine-print"><em><span>Helena Britt is co-chief investigator of the BEACH program. In 2013-14 BEACH was funded by a competitive grant from the Commonwealth Department of Health, and through University of Sydney research agreements with AstraZeneca Pty Ltd (Australia), Novartis Pharmaceuticals Australia Pty Ltd, bioCSL (Australia) Pty Ltd, and Merck, Sharp and Dohme (Australia) Pty Ltd. </span></em></p><p class="fine-print"><em><span>Clare Bayram does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>With GPs facing greater economic pressure and the health minister considering legislative change to make it easier for GP to charge them, GP co-payments, like Lazarus, may rise again from the dead.Christopher Harrison, Senior Research Analyst, Family Medicine Research Centre, Sydney School of Public Health, University of SydneyClare Bayram, Research Fellow, Family Medicine Research Centre, Sydney School of Public Health, University of SydneyGraeme Miller, Associate Professor of General Practice, University of SydneyHelena Britt, Associate professor, Director of the Family Medicine Research Centre, Sydney School of Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/328292014-10-17T02:30:36Z2014-10-17T02:30:36ZRising university fees threaten to skew public health services<figure><img src="https://images.theconversation.com/files/61761/original/3r8ktyhf-1413338200.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Will medical graduates with a hefty student loan be able to resist the higher paying specialties?</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>American medical graduates enter hospital training with a debt of around US$160,000 if they attended a public medical school, or US$190,000 if they attended a private school. In the United Kingdom, fees will be around US$60,000-80,000 for a four or six-year degree. If, as is predicted following deregulation, Australian medical students graduate owing fees of AU$120,000, this may be a significant factor in their choice of subsequent training.</p>
<p>A recent report from the <a href="http://www.biomedcentral.com/1472-6920/14/180">Medical Schools Outcomes Database project</a> suggests that around 13% of graduating medical students in Australia are keen to pursue a career in General Practice. This is less than the number wishing to become surgeons and paediatricians, yet it is within the ranks of general practitioners that we may see significant shortages of doctors, <a href="https://www.hwa.gov.au/our-work/health-workforce-planning/health-workforce-2025-doctors-nurses-and-midwives%20webcite">according to data from Health Workforce Australia</a>.</p>
<p>If graduates leave medical school with the purpose of recouping their debts, rather than hoping to make a difference in people’s lives and the health industry, the consequences for the state of public health could be dire: a shortage of general practitioners able and willing to work in public practice and bulk-bill the needy, and an over-supply of specialists in areas that aren’t necessarily required, but pay well. We probably have enough doctors into the future - they are just training in the wrong specialties! </p>
<h2>Why we need more GPs</h2>
<p>The Australian Institute of Health and Welfare released some <a href="http://www.aihw.gov.au/workforce/medical/types-of-medical-practitioners/">disturbing data</a> last week which suggested that while supply of GPs has remained relatively stable over the past decade at 110 full-time equivalents for every 100,000 people, the supply of other specialists has increased by 18% from 110 to 130 full-timers per 100,000 people. Specialists in Australia are <a href="http://dx.doi.org/10.1787/health_glance-2013-28-en">some of the best remunerated in the world</a> and earn at a rate around 4.7 times that of the average wage earner.</p>
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<a href="https://images.theconversation.com/files/61759/original/x5bnvcvc-1413338088.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/61759/original/x5bnvcvc-1413338088.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/61759/original/x5bnvcvc-1413338088.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/61759/original/x5bnvcvc-1413338088.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/61759/original/x5bnvcvc-1413338088.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/61759/original/x5bnvcvc-1413338088.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/61759/original/x5bnvcvc-1413338088.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/61759/original/x5bnvcvc-1413338088.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">GPs get paid a fifth as much as top specialists.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/downloading_tips.mhtml?code=&id=192683420&size=huge&image_format=jpg&method=download&super_url=http%3A%2F%2Fdownload.shutterstock.com%2Fgatekeeper%2FW3siZSI6MTQxMzM2NjQ1MywiYyI6Il9waG90b19zZXNzaW9uX2lkIiwiZGMiOiJpZGxfMTkyNjgzND">Shutterstock</a></span>
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<p>This country has a great system where the GP acts as a filter between patients and specialists. In America patients go directly to specialists, with the ensuing risk of costly and harmful over-diagnosis and over-treatment. </p>
<p>Yet our current system of fee-for-service payment is skewed towards the specialist – particularly procedural specialists. Medicare continues to pay more to specialists for doing simple operations than to GPs for thinking hard about the whole person.</p>
<p>GPs are paid <a href="http://www.melbourneinstitute.com/downloads/working_paper_series/wp2010n12.pdfaihw">around one-fifth</a> as much as some specialists. That seems unfair given GPs in Australia are trained to handle most health issues themselves, and only refer to specialists when the need arises. However, if a student is facing a student loan debt of A$100,000-$150,000, we can’t blame them for training as an ophthalmologist or dermatologist to repay that debt faster.</p>
<h2>GPs need an esteem lift</h2>
<p>The real issue is the standing of general practice and primary care in the health system. It is perceived to be not as desirable to be a rural GP as it is to be a surgeon or a specialist gastroenterologist or ophthalmologist. </p>
<p>In this era of chronic disease when Australians over the age of 65 will have on average four chronic diseases each, it is the GP who should be given top billing in the health system. GPs are well trained to keep an overview of the complexity of an ageing Australian. They know the patient and their family and can coordinate care between a number of specialists. </p>
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<a href="https://images.theconversation.com/files/61762/original/tg5pzqc5-1413338600.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/61762/original/tg5pzqc5-1413338600.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/61762/original/tg5pzqc5-1413338600.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=386&fit=crop&dpr=1 600w, https://images.theconversation.com/files/61762/original/tg5pzqc5-1413338600.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=386&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/61762/original/tg5pzqc5-1413338600.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=386&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/61762/original/tg5pzqc5-1413338600.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=486&fit=crop&dpr=1 754w, https://images.theconversation.com/files/61762/original/tg5pzqc5-1413338600.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=486&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/61762/original/tg5pzqc5-1413338600.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=486&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">GPs know their patients, and their patients’ histories and families.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<p>An esteem lift would require a substantial redirection of funding from hospitals to home-based primary care, an increase in health literacy in the community, and a recognition that GPs have an equal place in the health hierarchy as valued, broadly skilled cognitive specialists who rely on their diagnostic and medical management skills rather than primarily performing procedures.</p>
<p>To prevent a crisis in the primary care workforce, medical schools have to increase training in primary care and encourage their students to look for the rewards in medicine outside of remuneration.</p>
<p>Long portrayed as the hapless foot soldiers at the front line of health care, it is time for GPs to take on leadership roles as the generals at the very centre of the health system. If we can do that, future generations of doctors will be inspired to see more to medicine than debts and pay cheques. They will be excited at the prospect of dedicating their lives to helping others - while earning a decent living.</p><img src="https://counter.theconversation.com/content/32829/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Brooks receives funding from NHMRC .He is Executive Director Research Northern Health and a Professorial Fellow in the Schools of Population and Global Health and Medicine at the University of Melbourne.</span></em></p><p class="fine-print"><em><span>Steve Trumble is employed by the University of Melbourne and is a member of the Royal Australian College of General Practitioners.</span></em></p>American medical graduates enter hospital training with a debt of around US$160,000 if they attended a public medical school, or US$190,000 if they attended a private school. In the United Kingdom, fees…Peter Brooks, Executive Director Research Northern Health and Professor- Schools of Population and Global Health and of Medicine University of Melbourne h , The University of MelbourneSteve Trumble, Professor of Clinical Education & Training, Melbourne Medical School, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.