GP Education Night:Shoulder Disease

(Imaging & Treatment) – 1st November All welcome. For more information please phone: 0437 141 748

Dr Jeremy Price | Dr Iain Stewart | Dr Suet Wan Chen | Dr Malcolm Thomson | Dr Fred Lomas | Dr Paul Sullivan

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October2005

C a n b e r r a D o c t o r i s p r o u d l y b r o u g h t t o y o u b y t h e A C T A M A

At a recent ceremony atThe Canberra Hospital,Mrs Carol Herdson,widow of the lateProfessor PeterHerdson unveiled aplaque officially nam-ing the pathologymuseum at TheCanberra Hospital –The Professor HerdsonPathology Museum.

Speaking at the opening, col-league Dr Sanjiv Jain, Director ofAnatomical Pathology, said “weremember our Prof, ProfessorPeter Herdson, with great fond-ness. Not only we at ACTPathology but members of themedical community at TheCanberra and Calvary hospitals,the ACT Branch of the AMA, thelegal community, the judiciary,members of the ACT Police Forceand many others remember thevery generous, larger than lifegregarious personality of PeterHerdson. Peter Herdson wasDirector of Pathology at ACTPathology from 1991 to 2005 andhis Canberra colleagues were sad-dened to hear of the passing inlate June last year in Auckland.

As Dr Jain remarked, PeterHerdson was a man of manyfacets and the ACT AMA wasamong the organisations he madea contribution to – his personali-ty, his love of life, his generosity ofspirit, and his fondness for people– are long remembered and nowhonoured by this museum.

He was also the President ofthe World Association of Societies

of Pathology from 1993 to 1995.The Royal College of Pathologistsof Australasia presented him witha distinguished fellow award in2002 for his outstanding contri-butions to Pathology.

Peter and Carol Herdsonarrived in Canberra in July 1991when Peter took up the positionof Professor and Director of ACTPathology and from December1994 he was Professor ofPathology, University of Sydney(Canberra Clinical School).Immediately prior to taking upthis position, Peter was Professorand Chairman of the Departmentof Pathology and LaboratoryMedicine, the King FaisalSpecialist Hospital and ResearchCentre in Riyadh, Saudi Arabia.After six years there, he and hiswife Carol came to Canberra.

Peter Herdson was born on 29December 1932 in Auckland NewZealand. Peter graduated with apharmacy degree from Auckland,and then completed a B.Med Scand MB ChB in 1959 from Otago.Peter then completed a PhD inExperimental Pathology atNorthwestern University Medical

School in Chicago and joined theFaculty there as Associate ProfessorPathology.

Peter was appointed Foun-dation Professor of Pathology inthe University of Auckland Schoolof Medicine in 1969, a position heheld until he took up his appoint-ment in Riyadh.

Peter won many awardsincluding the John MalcolmMemorial Prize in Physiology andBiochemistry, University of Otago,Scott Memorial Prize in Anatomy,University of Otago MedicalSchool, Travelling Scholarship inMedicine, University of OtagoMedical School, New ZealandFellowship Bland-Sutton Institute,Middlesex Hospital MedicalSchool, London, OutstandingTeacher of the Year, NorthwesternUniversity Medical SchoolChicago, USA, Professor Emeritus,University of Auckland School ofMedicine, Auckland, HonoraryFellowship in the Royal Australianand New Zealand College ofRadiologists and Gold HeadedCane, World Association ofSocieties of Pathology. His lastaward as a distinguished fellow,from his own Royal AustralasianCollege of Pathologists, broughthim great joy and is a measure ofthe esteem in which his pathologycolleagues held him.

Peter was a prolific writerand authored or co-authored 88papers, six book chapters, twotheses and eleven editorials. Hesat on several editorial boards,national (NZ and Australian)advisory committees and was anactive member of many profes-sional bodies.

His forensic activities includ-ed Coroner’s pathologist inAuckland, NZ aviation aircraftinvestigator, Mt Erebus Disasterpathologist and Coroner’s pathol-ogist, Canberra.

Speaking at the official nam-ing, Health Minister, Mr SimonCorbell, said that during theyears Professor Herdson wasDirector of Pathology, his enthu-siastic encouragement supportedthe continuing development ofthe Pathology museum. PeterHerdson was instrumental inplanning the mortuary and thepathology Museum area. He hadinsisted that there be appropriatespace set aside for exhibiting thepotted pathology specimenswhere the medical studentswould also be taught in theirtutorial groups. He was an enthu-siastic teacher. It is fitting thatthis educational facility bears hisname and spirit.

“It was quite an honour toinvite Mrs Herdson to officiallyname the museum. She was cer-

tainly aware of his work and theappreciation shown by his workcolleagues and the many doctorswho studied at the Hospital,” MrCorbell said. “Under his leadershipACT Pathology became recognisedas the quality pathology providerfor the ACT hospitals. Pathologyregistrar training was markedlyexpanded in the ACT through hisefforts. He mentored the Pathologytrainees, who are now well knownpathologists around Australia.They warmly remember his untir-ing support and care. ProfessorHerdson was a strong supporter ofyoung doctors and was never toobusy to provide referees for doc-tors as they moved through theircareers,” Mr Corbell said.

Professor Herdson will longbe remembered with the museumhe established now bearing hisname.

Prof Peter Herdson.

Former ACT AMA President, Professor Peter Herdson hasPathology Museum named in his honour

Mrs Carol Herdson at the pathology museum at The Canberra Hospital.

Long term care schemefor catastrophicallyinjured

The major last component ofprofessional indemnity is thelong-term care scheme for thosecatastrophically injured in anyaccident. The excellent review byPrice Waterhouse Coopers pro-vides a concise proposal inexplaining the natural progress ofthe long-term care scheme. It isencouraging to see that all juris-dictions appear keen to progressthe idea of incorporating a no-fault long-term care scheme forthose catastrophically injured ini-tially as a component in a statuto-ry and no-fault motor vehicle andworkers' compensation schemes.

Some states have progressedfurther in this area and will viewwith interest the success of the NewSouth Wales "Lifetime care andsupport" motor vehicle accidentplan which proposes a no-faultscheme, and also proposes to incor-porate a scheme into its no-faultworkers' compensation scheme.

In the ACT without statutorymotor vehicle accident schemes,this needs to be incorporatedbefore any long-term care schemescan commence. The gradual piece-meal adaptation of schemes withinthese areas has been referred to asthe "layer approach" and specifiesthat all jurisdictions need to havein place statutory motor vehicleand workers' compensationschemes before any broader long-term care scheme can be imple-mented. They stated that those cat-astrophically injured from medicalaccidents could be easily fundedfrom current funding sources how-ever federal funding would contin-ue to be involved.

The AMA potentially has avital role within this process asdoctors are concerned to haveappropriate care in place for theirpatients injured in a motor vehi-cle accident or industrial acci-dent, and would also have thesame concerns for those injuredin medical accidents. It is impor-tant for the AMA to take this pub-lic interest stance and highlightthe fact that most catastrophicallyinjured do not have access to legalavenues and under any no-faultproponent of a long-term schemewould provide the required treat-ment and intervention at an earlyrather than later stage. Any con-tribution to such a scheme by themedical profession would be bal-anced by the benefit to loweringindemnity costs.

Healthcare complaintsThe Community and Health

Services Complaints Commission-er’s report has just been releasedoutlining a breakdown of com-plaints received to over the previ-ous 12 months. There were 440inquiries made to the Commiss-ioner 50 per cent confirmed inwriting as complaints and not allrelated to medical practitionerissues. 76 per cent of claims con-cerned private providers wererelated to medical practitionerswith dentists 12 per cent and psy-chologists 4 per cent. This hasincreased in whole terms from 19to 45 complaints relating to gener-al practitioners and other medicalspecialties have generallyremained static with 12 cases forsurgeons, 11 cases for physiciansand 7 for obstetricians.

What next?It’s amazing how the actions

of a few can change the availabili-ty of a medication. I refer to theVictorian government requestingthe TGA withdraw a brand ofantihistamine gel capsule becauseof some drugs abusers injectingthe contents into their veins. Thedecline of heroin on the streetsmakes those dependent desperateto inject what ever is available,and have turned to diphenhy-dramine (“Unisom Sleepgels”) forthis purpose. This follows theremoval of Temazepam gel cap-sules for the same reason someyears ago. A warning on theMedical Board website states thatGPs should be aware of patientsrequesting scripts for this medica-tion when it is available as an overthe counter preparation. Unlessthe patient is sneezing, one wouldbe doing them a favour by pre-venting potential significant vas-cular damage by irresponsiblyinjecting the contents of theseoral capsules.

Role substitutionThe report by the Productivity

Commission provide someglimpse into the future generalpractice which may give GPsmuch greater freedom and delega-tion of routine tasks to a widerrange of health workers. In theface of workforce shortages andthe commissions report allowsdoctors to delegate more work to"substitute providers" and claim arelevant MBS item. This providessome hope as it allows GPs tofocus on the degree of patient carewithin their practice and stillmaintain high care standards fortheir patients. The commission has

adopted the idea of a review com-mittee from the AustralianPhysiotherapy Association toallow a physiotherapist to refer toorthopaedic surgeons, obstetri-cians and gynaecologists and alsodirectly referring patients for diag-nostic imaging would save approx-imately 9500 hours of unnecessarygeneral practice consultations.While this may have some benefitfor investigating more straightfor-ward conditions, there has to besome limitations on the complexi-ty of problems investigated byphysiotherapists and the follow-upthat must follow when interpretingthe investigation results.

MBS GPs rates insultingto highly trained generalpractitioners

The new increase in the MBSfees for general practitioners hasincreased by only 2 per centwhich represents about half of the3.55 per cent increase recom-mended by the AMA for non-pro-cedural G P's. The indexationmethod does not take intoaccount the cost of running apractice, and for those using thenew bulk billing incentives willsee this eroded by this ineffectiveindexation. For GPs it must belike ordering a double decaf-feinated, Lo Cal skimmed milkwith a touch of soy milk latte –commonly referred to by high endbarristas as a “why bother”!

Patients abusing GPsIn a disturbing survey by

urban GPs recently published inthe MJA shows alarming instancesof physical and verbal abuse bypatients varying from direct assault

on GPs, property damage, slander,sexual harassment and stalking.The groups most vulnerable havebeen identified as female GPs andthose less experienced who workafter-hours and are more likely tobe facing confrontation withpatients. There is still a lack of anysystematic response to violencewithin general practice in Australiaand we should take the approachadopted by the UK National HealthService of the zero tolerance.Numerous emergency departmentsaround Australia adopt this policyof zero-tolerance of violenceagainst any member of staff, as theyare the ones who have to return towork the next day, and their safetyis paramount. Preventative strate-gies should be put in place inhealth sector as with other occupa-tions who endeavour test protect-ing its staff.

2

Dr Charles Howse

ACT AMA President’s report

O c t o b e r 2005

Evidence-based demen-tia diagnostic criteria

A particularly relevant sessionwas on evidence-based dementiadiagnostic criteria, commissionedunder the auspices of the Swedishgovernment Council on Technol-ogy Assessment in Health Care.Professors Gunhild Waldemarand Knut Engedal reported on theassessment of routine laboratoryscreening for the diagnosis ofdementia. There was little evi-

dence that thyroid disease causedreversible dementia, but it wasnoted that treatment of thyroiddisease my ameliorate associatedcognitive and psychiatric symp-toms. Similarly, there was a dearthof evidence on the associationbetween neurosyphilis and cogni-tive impairment in populationstudies, but reports of improve-ments with treatment. There wasmoderate evidence that elevatedhomocysteine was associated withcognitive impairment and AD, but

so far there was no evidence thattreatment with B12 or folate couldreverse or prevent dementia.Professor Henrik Zetterbergreported that CSF examinationremained largely a research tool.Professor Ole Almkvist reportedthat comprehensive cognitiveassessment batteries were mostuseful in diagnosing the cognitivechanges of dementias; but notedsignificantly that the MMSE and aclock drawing task were particu-larly useful single tests of cogni-tive function. Finally, ProfessorLars-Olof Wahlund reportedmedial temporal lobe atrophy isuseful in distinguishing ADpatients from controls. The caveatwould be that accurate measure-ments and comparisons need tobe made and this can prove diffi-cult in clinical practice.

Lewy Body dementiaAn update on Lewy Body

dementia was chaired by Pro-

fessors Ian McKeith and GlenSmith. There has been refine-ment of diagnosis of this relative-ly common (up to 10-15% of allcauses of dementia), but puz-zling disorder. Supplementarysupportive clinical features havebeen added to the cardinal signsof fluctuant cognition, fluctuantParkinsonism and visual halluci-nations. Those clinical featuresregarded as suggestive of LewyBody dementia are:� REM sleep behaviour disorder� Severe neuroleptic sensitivity� Low dopamine transporter

uptake in the basal ganglia asvisualised by SPECT or PET

Clinical featuresregarded as supportive:� Severe autonomic dysfunction

eg. Orthostatic hypotension,urinary incontinence

� Relative preservation of themedial temporal lobe onCT/MRI

� Reduced perfusion onSPECT/PET in the occipitalregion

� Abnormal MIBG (NuclearMedicine) uptake in the auto-nomic innervation of theheartNeuropsychological features

regarded as supportive were sum-marised by a meta-analysis byCollerton et al. (2004) DemGeriatr Cog Dis 16:229-37.Speech is characterised bydecreased verbal fluency, whilstvisual perception is evident inconstructional apraxia. Sleep fea-tures of daytime drowsiness, dis-organised speech and staring intospace (secondary to fluctuation inconsciousness) have also beenidentified.Jeffrey Looi

Report on the 12th Congress of the InternationalPsychogeriatric Association, 20-24th September, StockholmThis biennial congress is interdisciplinary innature, but this year the main focus was ondementia. Whilst there are the promise ofadvances, it would seem the majority are stillsome years from translation to clinical practice.I have summarised a couple of talks for thisissue, with more to follow in the next.

3O c t o b e r 2005

Determining the fund that isbest suited to your needs doesinvolve some research, but it’scertainly not a process thatbelongs in the “too hard basket”.Sure, our superannuation sys-tem is complex, but the keyissues surrounding super choiceare not, and you don’t need to bean expert on the topic to assesswhat is right for you. It’s more acase of familiarising yourselfwith what your existing fundhas to offer, and seeing if youcould do better elsewhere.

When you’re comparingfunds, the main aspects to con-sider include whether the fundhas earned a satisfactory return(relative to the risk involved),the range of investment strate-gies, the annual fees and thelevel of insurance cover the fundoffers. If, after taking a look atthese things, you are happy withyour current fund, then there’s

no reason to change. Most super funds can be

placed into one of the followingcategories� retail� wholesale� master trust/wrap� industry� corporate� self managed super fund

Retail funds and wholesalefunds are self explanatory. If youhave upwards of $50,000 insuperannuation then you shouldbe able to access wholesalefunds, which have lower fees.

Master trusts and wraps giveyou a far greater variety ofinvestment choice such as accessto a range of wholesale fundsand listed equities. For lowersums of monies these can befairly expensive but for largeramounts the fees become com-petitive.

Industry funds are a solidoption that have low fees and forsmaller sums are a great place tostart.

Corporate funds are thoseoffered by employers who usescale to get good rates for theiremployees.

Super choice may see moreAustralians taking a do-it-your-self approach to superannuation.Self-managed super funds(SMSFs) can offer considerableflexibility, but be aware thatunless you have a substantialnest egg – usually upwards of$200,000, the annual account-ing and audit costs will eat intoyour money. In addition, everymember of a SMSF is also atrustee of the fund – responsiblefor meeting the extensive legaland tax obligations governingsuper funds. These obligationscannot be delegated to anaccountant or solicitor, and evensimple mistakes can land thetrustees in serious trouble.

My advice is get advice. Findout what type of fund is best foryou given your circumstancesand then use that fund effective-ly. With the removal of thesuperannuation surcharge andsuperannuation splitting fromthe 1/1/06 superannuation isback in vogue.

This article has been contributedby King Financial.

Super Duper Super Funds

Canberra Doctors and Dentists meet with “Money” Maestro, Paul Clitheroe

Tom Glover, Jill McSpedden, John Sautelle and Mike Empson.

Do you know when you Do you know when you can afford to retire?can afford to retire?Making best use of

legislation?

Ask…King

For most Doctors, super choice may not generatea great deal of interest. That’s understandable –after all, super is money we can’t generally accessuntil we retire. And that’s often a long way downthe track. But it’s still your money, and thesedays, thanks to the superannuation guarantee,Australians are accumulating quite substantialnest eggs – around $78,700 on average for menof all ages, and $43,300 for women.

The National BrainInjury Foundation hasmoved to its perma-nent stall in the cen-trally located Griffin

Centre, Civic afterspending the last 12months operating froma temporary woodenYurt structure.

“I am pleased to see the Foun-dation permanently located on theground floor of the new GriffinCentre premises, Genge Street,Civic. The new Griffin Centrebuilding will house a number ofcommunity groups and is an

important step toward bringingemployment and social activityback to this part of the City,” MrCorbell said.

The ACT Planning and LandAuthority covered the costs of the12 month temporary accommoda-

tion, to assist the Brain InjuryFoundation provide essential serv-ices to sufferers of brain injury andtheir families while longer termaccommodation premises werenegotiated

Grant Alleyn of King Financial, Niran Pathmaperumaand Dale Lymn.

Ken Sunderland, Julie Murphy, Paul Clitheroe, Margherita Nicoletti and Tuan Tran.

Canberra Doctors andDentists were hosted todrinks at the Boathouserecently by KingFinancial Services. Guestof honour was “Money”maestro, Paul Clitheroe.

National Brain Injury Foundation settles in the new Griffin Centre

A senior obstetriciansays Australian womenshould have access tomedical abortion usingmifepristone (formerlyknown as RU-486),bringing their choicesin line with women inother countries.

In a recent issue of theMedical Journal of Australia(MJA), Professor Caroline deCosta, of the Department ofObstetrics and Gynaecology atJames Cook University, saysavailability of the drug inAustralia might largely overcome

many of the inequities of accessto abortion.

“Availability of the drug iscritical for many women in ruralareas and women in some ethnicgroups whose access to surgicalabortion is limited,” Professor deCosta says.

“Medical abortion should bean option for all Australianwomen.

“The overseas experiencehas shown it to be a safe, effec-tive and acceptable alternative tosurgical abortion.

“Medical abortion must beprescribed and administered by amedical practitioner with appro-priate experience after discus-sion with the woman and afterinformed consent has beenobtained.”

In the MJA, Professor deCosta tells the story of a young

mother with two children underthe age of three, both deliveredprematurely because of her severepre-eclampsia, who requested ter-mination of another pregnancy.

She was from a rural com-munity and her only access to atermination meant travellingseveral hundred kilometres to aprivate clinic.

The cost of this was beyondher means, and she remainedpregnant.

Once again, she developedpre-eclampsia, necessitating anemergency caesarean at 26weeks.

The infant died within 24hours, and the woman spent sev-eral days in a high-dependencyunit, covered this time by thepublic purse.

“This woman’s story couldhave been very different if

Australian women had access tomifepristone, a drug which issafe, effective, cheap to produce,and now widely used overseasfor medical abortion,” Professorde Costa says.

In 1999, the InternationalFederation of Obstetrics andGynaecology stated that ‘afterappropriate counselling, awoman has the right to haveaccess to medical or surgicalinduced abortion, and … health-care services have an obligationto provide such services as safelyas possible’. This view was sup-ported by the World HealthOrganisation.

While acknowledging thedesirability of reducing the highnumber of abortions carried outin Australia each year, Professorde Costa says, given the complexand compelling nature of human

sexuality, unwanted pregnancieswill continue, and Australianwomen will continue to seeksafe, legal abortion.

“The safety of abortion hasbeen shown to be directly relatedto how early in pregnancy it isperformed,” she says.

“The case for medical abor-tion in Australia should be judgednot on political grounds but sole-ly on evidence-based medical cri-teria.

“People have to rememberthat abortion is legal in Australia,which means that this emotivediscussion is all about the scien-tific evidence for medical abor-tion, not the legality of it,”Professor De Costa says.Professor De Costa’s letter toCanberra Doctor is below.

It’s time Australian women had access to medical abortion

4 O c t o b e r 2005

DisclaimerThe Australian Capital TerritoryBranch of the Australian MedicalAssociation Limited shall not beresponsible in any manner whatso-ever to any person who relies, inwhole or in part, on the contents ofthis publication unless authorised inwriting by it.The comments or conclusion setout in this publication are not nec-essarily approved or endorsed bythe Australian Capital TerritoryBranch of the Australian MedicalAssociation Limited.

A News Magazine for all Doctors in the Canberra RegionISSN 13118X25

Published by the ACT Branchof the AMA Ltd42 Macquarie St Barton(PO Box 560, Curtin ACT 2605)

Editorial:Christine BrillPh 6270 5410 – Fax 6273 0455

Typesetting:DFS Design GraphixPO Box 580, Mitchell ACT 2911Ph/Fax 6238 0864

Advertising:Betty RooneyPh 6270 5410 – Fax 6273 0455

Editorial Committee:Dr Ian Pryor – Chair/EditorDr Jo-Anne BensonDr Keith BarnesMrs Christine Brill –Production ManagerDr Ray Cook

Dr John DonovanDr Charles HowseDr Jeffrey LooiDr Tracey SohDr Peter WilkinsMs Gemma DashwoodMr Stefan Baku

Copy is preferred by Email or on disk in IBM “Microsoft Word” or RTF format, with graphics in TIFF, EPS or JPEG format. Next edition November 2005

Dear EditorMedical abortion for Australian women

I am writing to you about animportant matter for the health ofAustralian women. As you may bewell aware, medical abortion – inparticular the use of the drugsmifepristone (the former RU-486)and misoprostol – is now widelyavailable overseas. Women in theUnited Kingdom, most of WesternEurope, the United States, Canada,Russia, China, Israel, Turkey, NewZealand and many other countries,who make the decision to termi-nate a pregnancy, can choosebetween surgical termination ofpregnancy or medical abortion,which uses the two drugs to bringabout a process similar to naturalspontaneous miscarriage.

Medical abortion must takeplace under the supervision ofappropriately trained medicalpractitioners and only after anindividual woman has been coun-selled and well informed about theprocedure. Moreover women mustbe offered appropriate follow-upand screening services. Howeverthe abortion process, once initiat-ed, can be concluded at homealthough women must have 24hour access to emergency care as asmall proportion – less than 5 % –will require surgical completion ofthe termination, and a very smallproportion will need a blood trans-fusion. There is now a largeamount of evidence from overseasstudies and reports, involving mil-lions of women, to show that med-

ical abortion is safe, effective, andvery acceptable to women.

Mifepristone as an abortifa-cient is specifically denied toAustralian women under the Ther-apeutic Goods Amendment Act of1996. Mifepristone can only beobtained for use as an abortifacientthrough a cumbersome bureau-cratic process requiring a medicalpractitioner or institution to applydirectly to the Federal Minister forHealth. To date there has been nosuch successful application.

The right of women to choosemedical abortion has been endors-ed strongly by the Royal College ofObstetricians and Gynaecologists,the American College of Obste-tricians and Gynecologists, FIGO –the international body embracingall national organisations of spe-cialist obstetricians and gynaecolo-gists – and the World HealthOrganisation. However medicalabortion remains unavailable toAustralian women.

As a practising obstetricianand gynaecologist with more thanthirty years of experience caringfor women, I am concerned thatthis situation be rectified and thatAustralian women who have tomake a decision to terminate apregnancy be able to make thechoice about method for them-selves. I am currently seeking sup-port from women and menthroughout Australia, from a widerange of backgrounds, to bringabout removal of the restrictive

legislation, thereby enabling insti-tutions currently offering surgicalabortion services, and private prac-titioners, the opportunity to offermedical abortion.

As a member of the AustralianMedical Association I believe ourorganisation should be active inseeking legislative change toenable evidence-based medicalabortion to be available in Aust-ralia. I appreciate that not all ourmembers are pro-choice in thematter of abortion. However abor-tion is legal in all states althoughinequities of access continue toexist, particularly for rural womenand for women of certain ethnicgroups As well, there are manywomen who would prefer the pri-vacy and less invasive nature ofmedical abortion.

Recently AMA spokesmenhave supported calls for changeand improvement in existing stateabortion laws. I would now askthat the ACT Executive of theAMA give serious consideration toa discussion of this topic amongstmembers, with a view to request-ing the Federal Government toremove the legislation excludingmifepristone from Australia.

Yours sincerely,Caroline de Costa

(Professor de Costa is Professor ofObstetrics and Gynaecology, JamesCook University, Cairns Qld –Editor)

5O c t o b e r 2005

Violence in the work-place is a growing con-cern for health careworkers, prompting thecall for better surveil-lance, prevention andprotection measures.A recent issue of theMedical Journal ofAustralia looks at thestatistics, examines therisks and looks at pro-grams for managingaggression and violentbehaviour in generalpractice, tertiary hosp-itals and emergencydepartments.

Dr Klee Benveniste, ResearchFellow at the Australian PatientSafety Foundation (APSF) inAdelaide, and colleagues exam-ined the data collected using theAustralian Incident MonitoringSystem (AIMS). They found thatamong 42 338 incidents reportedfrom 1 July 2000 to 30 June2002, 9 per cent of all incidentsinvolved patients and physicalviolence or violent verbal ex-change. Staff injury was reportedin 5 per cent of cases.

The proportion of incidentsinvolving violence was higher inemergency departments (16 percent, with frequent involvementof mental health problems oralcohol or drug intoxication), andmental health units (28 per cent).

With the closure of publicpsychiatric hospitals in the pastdecade, more patients with men-tal illness are seeking care in pub-lic hospital emergency depart-ments, say the authors.

AIMS analysis highlights theimportance of understanding thecontributing and precipitatingfactors in violent incidents, andsupports a variety of preventiveinitiatives, including de-escala-tion training for staff; violencemanagement plans; improvedbuilding design to protect staffand patients; and fast-tracking ofpatients with mental health prob-lems as well as improved waitingtimes in public hospital emer-gency services.

Mr John Forster and col-leagues from Austin Health inVictoria say that strategies to pre-vent and manage violence andaggression in the health care set-ting have become a primary healthand safety issue. Through a seriesof vignettes, they highlight key ele-ments in developing a program forpreventing violent behaviour andaggression in a tertiary hospital.

Key components of the pro-gram include staff education andtraining, risk assessment andmanagement practices, the use ofpatient contracts and policy devel-opment.

Parker Magin and colleaguesfrom the University of Newcastlesay that occupational violence is aconsiderable problem inAustralian urban general practice.

Their research showed thatabout 64 per cent of GPs whoresponded to a survey had experi-enced violence in the previousyear. The most common forms ofviolence were “low-level” violence:verbal abuse (42.1 per cent), prop-erty damage or theft (28.6 percent) and threats (23.1 per cent). Asmaller proportion of GPs hadexperienced “high-level” violence:sexual harassment (9.3 per cent)and physical abuse (2.7 per cent).

They found violence was sig-nificantly more likely to be direct-ed towards female GPs, less expe-rienced GPs and GPs working inareas of social disadvantage, men-tal health problems and drug andalcohol problems. Younger GPsand GPs providing after hourscare were also at greater risk.

The authors concluded thatformal education programs inpreventing and managing vio-lence would be appropriate forGPs and doctors-in-training.

Associate Professor MarcusKennedy, Director of EmergencyServices at the Royal MelbourneHospital, says violence in emer-gency departments (EDs) hasreached a level that requires con-certed action and a shift in atti-tude – to eradicate a socially andprofessionally unacceptable peril.In some EDs, violence is a dailyoccurrence, with nursing staffreporting several episodes eachweek. He says violence in emer-gency departments is often under-reported — in a setting of carevictims are likely to excuse thebehaviour and lack the timerequired to complete reports onviolent incidents. The key to suc-cessful intervention is a strongpreventive orientation.

Dr Claire Mayhew andProfessor Duncan Chappell, in aneditorial in the same issue of theJournal, say that although inAustralia the risk of death or seri-ous physical injury from a violentworkplace incident is quite remote,each year about one Australianhealth worker is murdered at workand large numbers are either ver-bally abused, bullied or assaulted.They say the challenge for healthauthorities is to implement effec-

tive preventive strategies and azero-tolerance policy.

All workplace violence pre-vention strategies should bemulti-faceted and organisation-wide, and involve widespreadconsultation with all workers intheir development and imple-mentation, say the authors.

Workplace safety has been along-term concern for the AMA.The policy statement belowreflects that concern as a priorityissue. The policy is beingreviewed by the AMA currently.

Doctors’ Personal Safety andSecurity in the Workplace

The AMA recognises thatviolence against doctors is agrowing concern. This PositionStatement is provided in aneffort to reduce the vulnerabilityof medical practitioners, includ-ing trainees and registrars, thoseworking in rural or remote set-tings, and those providing afterhours care and home visits.

The statement is framedwithin a risk managementapproach, focussing on risk iden-tification, risk assessment, riskcontrol, and evaluation of theeffectiveness of risk managementstrategies. It is intended to guidethe violence management effortsof hospitals, practice managers,and individual doctors – theseparties should also keep up todate with current literature on thesubject. Their efforts are under-pinned by Occupational Healthand Safety legislation that placeson employers a general duty ofcare to provide and maintain asafe and healthy workplace. Thelegislation also assigns to eachemployee a duty to take reason-able care for their own health andsafety, as well as for the health andsafety of others who may beaffected by that employee’s acts oromissions at the workplace.

Violence risk managementneeds to take into considerationthe work environment as a wholerather than doctors in isolation.To be successful it requires thecommitment of managementthrough sufficient investment oftime, money and personnel. Thisincludes commitment to regularaudits of the organisation’s vul-nerability to violence to informrisk management planning.

Consultation with staff isessential for violence risk man-agement planning to be effective.A risk management methodologycan be used in conjunction withthe detailed knowledge of staff inthe local work environment todevelop tailored solutions to vio-lence problems. It may be appro-priate to assemble a workinggroup of staff to develop a vio-lence risk management plan.

What’s happening inCanberra’s hospitals?

“Canberra Doctor” will sur-vey our major medical institu-tions to see what policies theyhave in place to protect healthworkers from patient abuse andreport in the next edition.

Violence in the health workplace

6 O c t o b e r 2005

The AMA recentlylaunched its positionstatement on Aboriginaland Torres Strait IslanderHealth. AMA President,Dr Mukesh Haikerwal,highlighted the dispro-portionate burden of ill-ness and social disadvan-

tage compared to thegeneral population, dyingup to 20 years earlierthan their non-Indigenous brothers andsisters. This is a gapwhich has not lessenedin the last 10 years, DrHaikerwal said.

The chances of a non-indige-nous person reaching 65 years ofage are just under 90 per cent. Thechances of an Aboriginal andTorres Strait Island woman reach-ing 65 are 35 percent and 25 per-cent for a man. This is worse thanin Nigeria, Nepal and Bangladesh.

The statement repeats theAMAs call for governments to cor-rect the under funding of healthcare services provided to aborigi-nal peoples and Torres StraitIslanders. The AMA believes mostAustralians are unaware of the way

the system currently runs,which – unaltered – is destinedto keep failing.

The AMA calls on eachlevel of government to reviewhow they fund these servic-es,the amount that is fundedand the need for that fundingto reflect the needs anddemands that have grownwithout increases in fund-ing to match.

The position state-ment is available atwww.ama.com.au

AMA RoundupAMA continues to advocate for Aboriginaland Torres Strait Islander Health

Surgically implanted prostheses- important announcement

its highest, our national commit-ment to the mental health sector isfrighteningly inadequate and frag-mented.

“We need to improve access toappropriate care for people suffer-ing mental illness.

“We need to expand commu-nity services and provide more psy-chiatric beds, we need more psy-chiatrists and nurses and carers,and we need greater funding fromall levels of government. Patientsneed access to aftercare and hous-ing and better access to GPs.

“While the FederalGovernment has recognised theproblem and started to improvefunding, services and programs,much more needs to be done, espe-cially for children and young peo-ple if we are to slow down theincrease of mental health disordersin Australia,” Dr Yong said.

Mental health disorders are onthe rise in Australia: � One in five Australians aged

over 18 currently meet the cri-teria of suffering from someform of mental illness

� By 2013, over 100,000 peoplewill be affected by bipolar dis-order, an increase of 6 per cent

� By 2011, we’ll see a 10 percent rise to 41,000 in thenumber of people with schizo-phrenia

� Dementia and depression aremajor issues for Australia’sageing population

� By 2050, around 730,000Australians will be affected bydementia. The AMA Submission to the

Senate Select Committee OnMental Health, April 2005, con-tains a raft of AMA recommenda-tions to improve mental health carein Australia, and is available on theAMA website at www.ama.com.au

Mental health care inAustralia in the 21stcentury – ‘out of sight, out of mind’

AMA Vice President, DrChoong-Siew Yong, said that theNot For Service report intoAustralia’s mental health care sys-tem reveals a sad story of inactivi-ty, poor planning, under-fundingand under-resourcing by allAustralian governments in the faceof one of the biggest health chal-lenges facing the nation in the 21stcentury – mental health care.

Dr Yong, a psychiatrist, saidthe report presents a Dickensianpicture of ‘out of sight, out of mind’when it comes to caring for peoplewith mental illness.

“It is a case of governmentsshifting blame and responsibilityand ultimately failing a very largenumber of vulnerable Australiansand their families and carers at atime when mental illness has oneof the highest burdens of any dis-ease,” Dr Yong said.

“Mental health policy needsnational leadership from theFederal Government and a unity ofpurpose from the States andTerritories.

“At a time when demand forquality mental health services is at

AMA President, Dr MukeshHaikerwal, today called on theGovernment to do more to involveGPs in the planning for a nationalresponse to a possible flu pandemic.

Dr Haikerwal said reports yes-terday that the Australian SentinelPractice Research Network(ASPREN) is underfunded andstruggling show that the flu pan-demic response is failing before ithas even started.

ASPREN is a network ofunpaid volunteer GPs mainly inNSW and SA who act as an earlywarning system for evidence of

influenza, including bird flu, andother diseases, but the number ofvolunteer GPs has dropped to 51from 110 in 1994.

“Things are going too slowwith the pandemic response strate-gy and it is irresponsible not toinclude the GP population inresponse planning from day one,”Dr Haikerwal said.

“As the Government’s neglectof ASPREN shows, Australia istotally unprepared in the key areaof bio-surveillance, if the concernsraised by the AMA are notaddressed.

“If we are to repel the flu pan-demic threat, Australia needs anational bio surveillance system.

“The first step is to revitaliseASPREN by extending the net-work of GPs across all States andTerritories and provide the spe-cialised training and support toallow early detection of healththreats.

“This will require the involve-ment of the AMA.

“There must also be sophisti-cated communication networks tofacilitate rapid alerts, laboratorysupport, and centralised data collec-

tion systems,” Dr Haikerwal said.Dr Haikerwal said the

Government has had plenty oftime to establish a system thatcould activate a flu pandemicresponse strategy. In 2002 and2003, the AMA alerted theGovernment that the national biosurveillance capacity was insuffi-cient to deal with a possible SARSoutbreak.

“The Government must heedthe lessons learnt from the threatspresented by the SARS outbreak.They must act now – and fast,” DrHaikerwal said.

Government must involve GPS in frontlineresponse to possible flu pandemic

Private Health Insurance coverarrangements for surgicallyimplanted prostheses have changedwith effect from midnight on 30October 2005. You need to knowwhat the changes are to fully informyour patients so read on.� Private health insurance funds

are no longer required by leg-islation to provide 100% bene-fit cover (no gap) for all surgi-cally implanted prostheses.This means patients may haveto pay a gap in some situationsand it is vital doctors under-stand where this will occur sothey can tell their patients.This new arrangement com-mences from midnight on 30October 2005 and will applyto any prosthesis used in sur-gery from that time on.Clinical choice remains theparamount consideration.

� The likelihood is your patientswill not be much affected bythis change. There is a mini-mum requirement for at leastone clinically appropriateprosthesis to be available foreach MBS procedure at 100%benefit cover (no gap). In real-ity, for most MBS items, therewill be a full range of no gapprostheses. The prostheses

have been classified into clini-cally meaningful groups by cli-nicians and clinicians areinvolved in the relevant deci-sion making bodies.

� The reforms are intended tointroduce greater competitioninto the way prices and bene-fits are set for the provision ofsurgically implanted prosthe-ses. This will enable a greaterrange of prostheses to maketheir way onto the ProsthesesList and in the long run, willimprove the quality of careprovided to patients and keeppremiums down.

� Informed financial consent forpatients is the key. If you thinka prosthesis that attracts lessthan 100% benefit cover (gapto patient) is the only onesuitable for the job, you needto explain the reasons for thisto the patient and, where pos-sible, tell them how much thegap will be. This should bepart of the broader informedfinancial consent you provideabout medical services. Ifthere is no gap, tell the patientthat too. In an emergency, tryto use a no gap prosthesis.

� The Australian PrivateHospitals Association and

Catholic Health Australia havecomprehensive informationpackages regarding thereforms on their websites. Ifyou want to know what pros-theses are on the List, whichhave full cover and whichattract a patient gap, go toapha.org.au or cha.org.au.Where there is a gap, the Listspecifies the maximum gapwhich the patient may face.

� To download the AMAInformed Financial Consentform, which includes theinformation to be given to thepatient on prostheses, go toama.com.au, apha.org.au orcha.org.au

� If you have general questionsabout the new arrangements,contact your hospital adminis-tration or ring John O’DeaAMA on 02 62705400, PaulMackey, APHA on 0262739000 or Patrick Tobin,CHA on 02 62605980.It is very important that these

new arrangements come insmoothly and that patients are notexposed to unexpected gaps.Please take some time to becomefamiliar with the new arrange-ments.

7O c t o b e r 2005

Entries are invited for:Healthcare Receptionist of

the Year: the entrant judged to bethe most outstanding Healthcarereceptionist will receive a cash

prize of $1,000.00 from John

James Memorial Hospital and a

$200 Gift Voucher from David

Jones.

New Healthcare Receptionistof the Year (New to the role with-in the last 18 months): the win-ning entrant will receive a cashprize of $500.00 from John JamesMemorial Hospital and a $100Gift Voucher from David Jones.

Conditions of EntryAll nominees must be 18

years or over at the date of nomi-nation lodgment and be employedas a receptionist in a Healthcarepractice in the ACT. The attachednomination form should be com-pleted by either a peer, Medicalpractitioner or patient.

Closing dates for entries isFriday 11 November 2005 at 5pmand forwarded to:

The SecretariatHealthcare Receptionistof the YearC/- John James MemorialHospitalPO Box 23DEAKIN WEST ACT 2600NO LATE ENTRIES WILL BEACCEPTED

Awards presentationThe Healthcare reception of

the year and New Healthcarereceptionist of the year will beannounced in at the SecretariesChristmas Party on Thursday 1December 2005 at the The Lobby,King George Tce, Parkes ACT.

JudgingA panel of two independent

judges will assess all nominationsand select finalists to be inter-viewed. Finalists will be inter-viewed on the following criteria.The judges decision will be finaland no correspondence will beentered into.� The level of contribution the

nominee makes to the sur-gery or practice;

� Effectiveness and efficiencyof the nominee;

� The level of understanding ofthe role of a Healthcarereceptionist; and

� Empathy with the position.

John James Memorial Hospitalincorporating Lidia Perin Memorial Hospital2005 Healthcare Receptionist of the Year Awards

HEALTHCARE RECEPTIONIST OF THE YEAR APPLICATION FORM 2005Before completing and signing this form, please read theinformation on the other side which contains the terms andconditions.If space is insufficient, please attach additional pages.

Name ___________________________________________

Name and Address of employer _______________________________

__________________________________________________________________________________________________

Telephone (business) ____________________________________________

Relationship to nominee (eg professional) ___________________

How long have you known the nominee? ____________________

1. What do you regard as the three most outstandingqualities of the nominee?

(a) _________________________________________________________________

(b) _________________________________________________________________

(c) _________________________________________________________________

2. Give a brief description why you feel your nomineeshould receive the Healthcare Receptionist of the Year

Award or New Healthcare Receptionist of the Year Award.

(Please attach additional page if required)

__________________________________________________________________________________________________

__________________________________________________________________________________________________

3. The nominated healthcare receptionist is encouraged to

submit a written statement on their own perceptions of

their role to assist the judges short list for interview. (state-

ments should be no more than one typed page).

Please include the following:

1. Why you feel you should receive the award.

2. Your interpersonal skills.

3. Customer Service

4. Professionalism

5. Technical Skills.

Please enter my nominee in the: (tick the appropriate category)

�� Healthcare Receptionist of the Year

�� New Healthcare Receptionist of the Year

�� Signature of nominee

�� Name of nominator

�� Signature of nominator

Applicant must be supported by the principal of the prac-

tice. (Practice Manager, GP, Specialist)

Name _______________________________________________________________________________________

Title _________________________________________________________________________________________

Statement of support.

I support the nomination of __________________________________________________

for the Receptionist of the Year Award.

Signature ___________________________________ Date ________________

John James Memorial Hospital supported by theAustralian Practice Managers Association, invitesnominations of Healthcare receptionist employedby general practitioners and specialists in the ACTto enter the 2005 Healthcare Receptionist of theYear Awards. The Awards give public recognitionof the dedicated, committed and skilled workperformed by Healthcare receptionists throughoutthe Canberra region.

✁

8 O c t o b e r 2005

“Passing the Baton” – The Canberra Hospital’s clinical handover projectEvery year at least 15%of patients in hospitalsaround Australia sufferan adverse outcome,which is unrelated totheir reason foradmission, HealthMinister Simon Corbellstated during thelaunch of the CanberraHospital’s ClinicalHandover Project.

These outcomes range frominfection to delays, and at worst,the unexpected death of a patient.It is estimated that 50% of thispatient harm is potentially pre-ventable.

At the launch of the clinicalhandover project, named Passingthe Baton, Mr Simon Corbell, saidthe project aimed to identifyopportunities to improve the safe-ty and quality of care provided tothe Canberra community.

“The Clinical Practice Im-provement Unit has targeted com-munication between clinicians asa priority for improvement,” MrCorbell said.

“In particular, the Unit willconcentrate on clinical handover,which is the exchange of informa-tion of patients between healthcare providers at the change ofshift or change of patient location.

“Clinical handover has beenidentified nationally and interna-tionally as a priority area to addressfor all healthcare institutions. Thehospital executive and clinicalmanagers have engaged with con-

sumers, doctors, and nurses toassist in improving the clinicalhandover and reducing potentiallypreventable patient harm.”

Each project has a dedicatedteam consisting of a consumerand a group of clinicians who arepassionate about improving clini-cal handover.

“The Project Teams are mak-ing changes in formalising the han-dover process that occurs betweenevening and night shifts to ensureall relevant information regardingthe patient is passed on to the med-ical officers, senior nurses, andmidwives,” Mr Corbell said.

Changes implemented to dateare being trialed and their effec-tiveness evaluated. The changesthat demonstrate improvement incommunication will be imple-mented permanently and used toimprove communication in otherclinical areas.

“The aim of the ClinicalHandover Project is to ensurethat handovers will cease to be aprimary factor in adverse eventsat TCH by March 2006,” MrCorbell said.

Background to theProject

The Clinical Practice Im-provement Unit supports the pro-vision of care that meets the high-est level of quality and safety atThe Canberra Hospital. This isachieved through clinical auditand review, consumer liaison, sup-port of clinical governance com-mittees and facilitation of ClinicalPractice Improvement initiatives.Patient safety and quality issuesidentified through current auditand review processes form thebasis of Clinical Practice Improve-ment initiatives undertaken with-in the unit.

The Clinical Review Comm-ittee identified the lack of commu-nication within the clinical settingas one of the major contributingfactors to adverse patient events atThe Canberra Hospital in 2004.

The Australian Council forSafety and Quality in Health Carehas identified clinical handover asa national priority for healthcarequality improvement. In addition,large body of work has beenundertaken internationally on thistopic with the United KingdomNational Health Service address-ing clinical handover as a patientsafety priority.

The Canberra Hospital Clin-ical Practice Improvement teamwas tasked with facilitating a proj-ect to improve patient outcomeswithin three domains of handover: � Resident medical officer han-

dover between shifts; � Nurse and midwife handover

between shifts; and � Handover between Emergency

and the Medical and Nursingteam accepting care.To date the project has engag-

ed with consumers, doctors, nurs-es and managers throughout theorganisation to investigate causesfor the breakdown in handover ofclinical information. Over 60 con-sultation meetings have beenheld. These included meetingswith hospital executive, clinicalmanagers, specialist medical offi-

cers, nurses, junior medical offi-cers and new graduate nurses.

Each project has a dedicatedteam consisting of a consumerand a group of clinicians who areenthusiastic about improving clin-ical handover. From the informa-tion gained during stakeholderconsultation, the project teamaddressing resident medical offi-cer handover is making changesin the following areas:� Improving the availability of

information regarding patientsadmitted after hours; and

� Formalising the handoverprocess that occurs betweenevening and night rosteredresident medical officers toensure that all relevant infor-mation regarding sick patientsis passed on to the medicalofficer responsible for theircare after hours.The project team addressing

handover from Emergency to themedical and nursing teams accept-ing care of the patient are makingchanges in the following areas:� Formalising lines of responsi-

bility for patients who havebeen accepted by a team andwho remain in Emergencyawaiting a ward bed;

� Formalising the documenta-tion of care and managementplans for patients who havebeen accepted by a team andwho remain in Emergency

awaiting a ward bed; and� Standardising nursing han-

dover from Emergency to thenurses accepting care on theward in line with current evi-dence based practice standards.The project team addressing

nursing and midwifery handoverbetween shifts are making changesin the following areas:� Standardising nursing han-

dover between shifts in linewith current evidence basedpractice standards; and

� Formalising the handoverprocess that occurs betweenday and after hours rosteredsenior nurses to ensure thatall relevant informationregarding sick patients ispassed on to the senior nurseresponsible for their care.Trials of the changes imple-

mented to date, as outlined above,are being held and their effective-ness evaluated. Changes leadingto demonstrated improvement incommunication will be imple-mented permanently and used toimprove communication in otherclinical settings.

The aim of the Clinical Hand-over Project is that clinical han-dover will cease to be the primarycontributing factor to adverseevents at The Canberra Hospitalby March 2006.

The project has been under-way since mid 2005.

American Mania – Whenmore is not enough

Peter C. Whybrow,WW Norton & Co:

New York, 2005ISBN 0-393-05994-4,Hardcover, 338pp,

US$24.95Reviewer –

Dr Jeffrey LooiWhilst in Los Angeles, I

picked up this book at the UCLAWestwood bookstore and wasintrigued that it was written by aneminent psychiatrist and campusneighbour, Professor Peter C.Whybrow, Director of the Jane andTerry Semel Institute for Neuro-cience and Human Behaviour. Thisbook is best described as popularneuroscience and neuropsychiatry,explicating the biological, psycho-logical and social bases ofAmericans’ “appetite for life”. Thisfollows in the trend in populariza-tion of life sciences by scientificauthorities and communicatorssuch as Matt Ridley, RichardDawkins, Antonio Damasio,Steven Pinker and Edward O.Wilson. The book skillfully com-bines journalistic exposition withcutting edge genetics, neuro-science, economics, psychology,psychiatry and anthropology.

Dr Whybrow advances thecentral thesis that the confluence of

American capitalism, centuries ofthe success-orientated immigrantsand the unparalleled prosperity(with of course exceptions, as seenin the South) has overloaded theAmericans with a profusion of pos-sibilities. He posits that American’sintense striving for success,observed even by Alexis deTocqueville in his surveyDemocracy in America in 1835,has become a recursive obsessionwith acquisition and consumption.In this last aspect, Dr Whybrowlikens the American desire to suc-ceed and consume to the psychi-atric diagnosis of mania. “Thus, weAmericans, must ask, to what pur-pose is our manic striving? Why dowe live in this way in a land wherewe are free to choose? Have we fall-en victim to the illusion that onlymore of what we have can be bet-ter?” (pg 261)

He contends that it is thisconsumerism that has drivenrecord levels of debt, obesity; con-tributing to the development ofstress, anxiety and depression sec-ondary to the disjunction betweenthe dream of success and the real-ity of striving. His writes thatAmericans are at perhaps a criticaljuncture, at a point where theyshould work towards evening thebalance between the pursuit ofindividual success and society.Perhaps it is timely to review thesematters, as we, in Australia, faceindustrial relation reforms that

have the poten-tial to shape a similarAmerican-style manic workculture in which we may increas-ingly work 24/7.

Interestingly, Dr Whybrow,who resides in both rural NewHampshire and Los Angeles (with-in walking distance to his office inWestwood) may well himself char-acterize in this pattern of commut-ing psychologically or physicallybetween the tension described inJay McInerney’s Bright Lights, BigCity – the city like LA or New York,which might consume you whole –and the more sheltered, lower hori-zons of smaller communities suchas the urban enclaves of SantaMonica, LA or Soho, New York.

In summary, this is a fascinat-ing book, written fluently andengagingly. Dr Whybrow has andinterwoven a modern neuropsy-chiatric understanding of andcharacterised this manic drive ofthe Americans, captured elo-quently in F. Scott Fitzgerald’squintessential American novel:

“Gatsby believed in thegreen light, the orgastic futurethat year by year recedes beforeus. It eluded us then, but that’sno matter – tomorrow we willrun faster, stretch out our armsfurther… And one fine morning–” (pg 171-172, Penguin Classicsedition)Dr Jeffrey Looi is a Canberra neu-ropsychiatrist

Book Review

� It may seem remarkable, butat a time when globalchanges in public health arebeing driven by a rampantcorporate ideology basedaround privatisation and“innovation,” calls are beingmade to make bioethics (anatural normative opponentof corporate globalisation)more evidence-based.Halpern argues that purport-edly authoritative statementsof Bioethics often containsunfounded assumptionsabout human moral behav-iour. He describes recentexamples in which assump-tions made in theoreticalwritings were later repudiat-ed, or in which empiricalwork served further to clarifypositions taken in theoreticalpieces. ((2005) 331 BMJ 901-903).

� Calls have been made tocompulsorily licence thepatented pharmaceuticalTamiflu as a precautionagainst avian influenza.Compulsory licensing occurswhen a government (for rea-sonable compensation)allows another manufacturerto produce a patented prod-uct (medicine) or process fordomestic use without theconsent of the patent owner.It is one of the flexibilities onpatent protection included inthe WTO's agreement onintellectual property – theTRIPS (Trade-Related Aspectsof Intellectual PropertyRights) Agreement. The 2001Doha Agreement on TRIPSand Public Health confirms

that countries are free todetermine the grounds forgranting compulsory licences.On 30 August 2003, theTRIPS General Councildecided to waive the domes-tic use requirement, allowinggeneric copies made undercompulsory licences to beexported to countries thatlack production capacity, pro-vided certain conditions andprocedures are followed. AllWTO member countries areeligible to import under thisdecision, but 23 developedcountries are listed asannouncing that they will notuse the system to import: oneof them is Australia.

� From November 2005, theUnited Kingdom Medicinesand Healthcare ProductsAgency, a body like our TGAentirely funded by user fees,will begin producing PublicAssessment Reports of eachnew medicine its licences.These will include summariesof the clinical trial data thatformed the basis of the man-ufacturer’s applica-tion.((2005) 331 BMJ 834-6)

� The Dickey Amendment,passed annually by the USCongress forbids federalfunds being spent on experi-ments that endanger ordestroy an embryo. Australiaalso has restrictive legislationin this area. Earlier in 2005,researchers in South Koreaused nuclear transfer toderive human ES cells thatgenetically matched thepatient (Nature 435, 393;2005). Rudolf Jaenisch and

Alexander Meissner of theMassachusetts Institute ofTechnology have nowdescribed in Nature a variantof therapeutic cloning calledaltered nuclear transfer(ANT), in which a gene per-mitting uterine implantationin the patient's donated cell isswitched off before the nucle-us is transferred into a fertil-ized egg. A team led byRobert Lanza of AdvancedCell Technology in Worcester,Massachusetts, has derivednew ES cell lines from blas-tomeres, while the 8 cellembryos went on to formapparently healthy mice. Thisresearch enhances prospectsfor stem cell research.

9O c t o b e r 2005

Terrace Level, Manuka Plaza, Flinders Way, ManukaTel: 6260 8080 Fax: 6260 8181Email: book@manukaplazatravel.com.auwww.manukaplazatravel.com.auIndependently owned and operated by Pontevedria Pty ltd ABN 41 078 134 175 Licensed Agent 335/D

Dr John Donovan and staff offer consultations on your professional and leisure travel

Dr Thomas Alured FaunceBA LLB (Hons) B Med. PhD.Lecturer ANU Law Faculty(Health Law, Ethics and Human Rights)Senior Lecturer ANU Medical School(Chair: Personal and ProfessionalDevelopment)Project Director, Globalization and HealthCentre for Governance of Knowledge andDevelopment, RegNet, ANUPh: (02) 6125 3563

Bioethics from the Journals with Dr Thomas Faunce

General practice, govern-ment and consumer representa-tives met in Melbourne recentlyto discuss how to best spend thehealth dollar. The forum, hostedby the Australian Primary HealthCare Research Institute, is dis-cussing whether fundholdingwould be a viable financing sys-tem for health care in Australia.

Immediate past President ofthe AMA Council of GeneralPractice, Dr David Rivettaddressed the meeting on behalfof the AMA. He asked why fund-holding continues to be on theagenda of some health organisa-tions. He said: “The Minister forHealth and Ageing said in a news-paper article in July 2005 that theFederal Government had nointention of introducing fund-holding and that such a systemhad a very limited place in theAustralian health system. He alsosaid and I quote “…fee for serviceis the basis of our health systemoutside hospitals and it works. I’mnot attracted by other modelsbeing used overseas. If you askedpatients whether they would pre-fer to be treated in the UK’sNational Health Service or inAustralia, they will say Australia.It offers great benefits to patients”.So I have to ask. Why are we hereyet again debating the issue offundholding for Australia?”

The AMA has developed aposition on fundholding basedon consultation with members.The AMA believes that fund-holding leads to a situation ofrationing of care. Under a fund-holding system, GPs face pres-sures, within capped budgets, tominimise expenditure on servic-es. This creates an ‘ethical haz-ard’ because the provider isobliged to extend the ‘duty ofcare’ from the individual to theneeds of a population.

Dr Rivett highlighted theoverseas experiences that demon-strate best quality patient healthoutcomes are not supported byfundholding. “A recent Statementon Safe Practice in anEnvironment of Resource Limit-ation prepared by the MedicalCouncil of New Zealand openswith the line “The rationing ofhealth services is becoming moreexplicit.”

“The statement providessome guidance to doctors butconsistently highlights the abso-lute tension between a financingsystem that is based wholly and

solely on cost drivers and thedoctor’s objective of providingthe best health care to his or herpatient. Basically the financialrisk for providing a service con-flicts with the quality of its provi-sion. The following is a goodexample of the type of guidanceincluded in the Statement:“Doctors have a responsibility tomake clear to any patient towhom care of proven effective-ness is being denied by any fun-der or provider, that what isbeing provided is not ideal care,by generally agreed standards ofmedical practice””.

A recent article published inthe journal ‘Australia and NewZealand Health Policy’ said: “TheNew Zealand scheme is com-plex, but closely resemblesUnited States insurance-based,risk-rated managed careschemes.” One of the advantagesproponents of the New Zealandsystem often cite is that GPs haveautonomy to set their fees andcontrol the governance struc-tures. However this article found“initial evidence suggests thattotal costs are higher than initial-ly expected, and prices to somepatients have risen substantial-ly…. Limited competition andNZPHCS governance require-ments mean current institutionalarrangements are unlikely tofacilitate efficiency improve-ments. System design changestherefore appear indicated.” Itimplies that GPs setting theirown fees and a fundholding sys-tem cannot operate successfullyin tandem – it is all or nothing.

“I think it is worth empha-sising that what is being dis-cussed is a financial system thathas to date nothing behind itthat relates to patient outcomesor quality of care. Fundholding,certainly as it is being promotedin some quarters, is not aboutpatients, its not about providingbetter health care it is not aboutimproving patient outcomes – itis about driving down costs.And without the capacity todemonstrate otherwise there is avery substantial risk that drivingdown the costs through fund-holding will compromise thevery reasons we are in generalpractice – that is delivering bestquality care to our patientsbased on clinical need,” DrRivett said.Reprinted from AMAs GPNetwork News.

Health financingexamined

Under a new arrangementbetween the CommonwealthBank and the AMA Victoria,members can access theBank’s innovative range ofmerchant terminals at aspecial Merchant ServiceFee on credit cartransactions of 0.85% of thetransaction value.

Choose from Australia’sfavourite EFTPOS terminal,Comm2000, or Paylite,which is ideally suited forsmaller Businesses withlower transaction volumes.

To find out more, contactHeidi Sauers at AMA ACTon 6270 5410

You do not have to be a Commonwealth Bank customer to take up this offer. Applicants for this offer consent to their name and merchant identification being provided to AMAACT to confirm membership and eligibility for the offer. For debit card transactions, the Merchant Service Fee is 0.05% of the transaction value. Bank fees and governmentcharges apply. Full terms and conditions available on application. Other fees and charges may apply. All fees and charges are inclusive of Goods and Services tax (GST) Feessubject to changes at the Banks’ discretion. Commonwealth bank of Australia ABN 48 123 123 124.

1 0 O c t o b e r 2005

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Dr Janelle McDonald

FOR LEASEConsulting rooms in Isabella

Plains Medical Centre3 rooms totalling 80 squaremetres plus common area.

For inspection & detailsplease phone:

6293 1140 or0422 355 600