Introduction
This year in health, as in most years, has been exciting. There have been a number of ‘wins’ and a whole host of new challenges.
The successful adoption by the Council of Australian Governments of the National Registration and Accreditation Scheme for all health professions will reassure the Australian community that all health professionals are appropriately trained and registered to undertake their tasks. We have also continued to work with the Deans of medical schools and professional colleges to ensure our training programs in medical schools and vocational training reflect the realities of today's medical practice. In other areas we made gains in Indigenous health, with Aboriginal and Torres Strait Islander children having a health check, and made appropriate arrangements to identify health problems and manage them in culturally sensitive ways. A number of other important strategies have been established to improve maternal and child health, as well as addressing some of the lifestyle factors that impact on the development of chronic disease in a disproportionate manner in this segment of our community. There have been other achievements, including: the successful rollout of the human papilloma virus vaccination program; the establishment of the Cognate Committee to look at ways of introducing best practice in the area of organ donation and transplantation; and new initiatives in providing better access to primary care.
The year has not been without challenges though. We had the worst seasonal influenza outbreak that has occurred for a number of years and lessons learnt were that our national ‘real time’ influenza surveillance needs to be strengthened. At the same time, Australia took a leadership role in trying to resolve the complex international issues around virus sharing by attempting to reconcile the different views of a large number of interested countries. This year we were confronted with the problem of a previously unknown contaminant in the anti-coagulant Heparin that has affected worldwide supply of this drug.
Prevention and the management of chronic disease has become a central theme of our activity: obesity has been announced as a national health priority; and a new Preventative Health Taskforce has been established with its early work focusing on alcohol, tobacco and obesity. New and ongoing work in cancer care included funding for: a Comprehensive Cancer Centre; two centres for research into prostate cancer; additional resources focused on gynaecological cancer; and a number of other projects.
The Office of Rural Health was established which will bring many of our ongoing projects together, so we can better coordinate our activities in the area of rural health and deliver better services, particularly in primary care.
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Professional Practice
In March this year, First Ministers signed the Intergovernmental Agreement to establish a national system for the accreditation and registration of nine health professional groups (chiropractic, dental, medical, nursing and midwifery, optometry, osteopathy, pharmacy, physiotherapy and psychology). There will be nine individual professional registration boards reporting to health ministers, a single national structure for administration, with state offices implementing the nationally agreed regulations locally. This will ensure national consistency of recognition of skills as well as professional mobility, and will come into force in 1 July 2010. In combination with these changes, a new nationally consistent approach to the recognition of international medical graduates has been put into effect. This will ensure that they all have their prior learning appropriately assessed. Where appropriate, international graduates will be given credit for prior learning and experiences, so that they can enter the workforce without delay, with assurances that these doctors are of a uniformly high standard. Medical training has also been a major focus with successful Australian Medical Council accreditation of a number of the new medical schools. With the increase in the number of graduates following the expansion of medical school places, there has been ongoing work with all stakeholders to ensure that appropriate numbers and quality of postgraduate training places are available for these graduates to enter, following completion of medical school. This expansion of training encompasses the community and private sectors, as well as the traditional public sector training environment. This change will ensure that the training of our medical professionals is better aligned with how diseases are currently managed in our community.
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Cancer
Cancer, heart disease and strokes are the leading causes of premature death in Australia. With the ageing of the population and the success in managing acute vascular events, it is little wonder that cancer is challenging heart disease as our principal cause of death. To be successful, the fight against cancer needs to be managed on a number of fronts, ranging from prevention through to early detection, management and palliation.
This year has again seen new initiatives that have built on past success. In the area of prevention, a renewed focus has been on smoking, obesity and excessive alcohol intake; all of which are causal factors in a large number of cancers. For example, epidemiological evidence suggests that alcohol increases the risk of oesophageal cancer.
1 The programs in the future will work at targeting particularly vulnerable groups. The rollout of the vaccine to prevent infection with the human papilloma virus, which is a precursor for cervical cancer changes, is a world first and many countries are looking to us to learn how to manage such a complex task. This year 3.4 million doses of the human papilloma virus vaccine were distributed. A National HPV Register is due to be completed in November 2008 and come into full operation in early 2009. Through the register, the Department will monitor coverage rates and vaccine effectiveness to ensure that the program is operating successfully.
The area of early detection of cancer, has been supported by an important and successful series of programs, including BreastScreen Australia, the National Cervical Screening Program and the National Bowel Screening Program. The Department has commenced a wide-ranging evaluation of the BreastScreen Australia Program under the direction of the Australian Health Ministers’ Advisory Council. The evaluation will examine the benefits of the program in terms of reduction of breast cancer death rates and the risks associated with screening. It will also assess and address the ongoing and emerging issues that affect the program, and identify opportunities for overall improvement. We expect the evaluation to be completed in 2009.
The Department has also conducted comprehensive reviews of new technologies for the early detection of breast cancer such as digital mammography and Magnetic Resonance Imaging to ensure the most up-to-date technology is available in the early detection of breast cancer. Similarly with new technologies and the impact of the human papilloma virus vaccination, the Department will review the cervical screening program to ensure that this large program delivers the best outcomes.
Over one million invitations to participate in the National Bowel Cancer Screening Program have been sent to eligible Australians since its inception in August 2006. In 2007–08, 627,000 invitations to participate were sent out. Just over 40 per cent of those invited have been recorded as participating so far. A total of 7.7 per cent of those who have participated in the program so far had a positive faecal occult blood test result. Either (suspected) cancers or pre-cancerous polyps were detected in 60 per cent of participants with a positive result, which were further investigated by colonoscopy. Fifty-two cancers have been reported to the Program Register so far. We will extend the program to screen people turning 50, 55 and 65 years of age between January 2008 and December 2010.
To optimise the care of patients with established cancer, many new effective drugs have been added to the Pharmaceutical Benefits Scheme at a cost of around $82 million over the years 2007–08 to 2010–11. These include Lapatinib for metastatic breast cancer ($19 million over the years 2007–08 to 2011–12), Dasatinib for chronic myeloid leukaemia and acute lymphoblastic leukaemia ($7 million), Bortezomib for multiple myeloma ($28 million), Cetuximab for throat cancer ($8 million) and the extension of Pemetrexed to the treatment of mesothelioma ($20 million). There have also been new listings on the Pharmaceutical Benefits Scheme that will help to prevent cancer such as the drug Varenicline to help people quit smoking at a cost of $75 million over the years 2007–08 to 2011–12. Funding has also been made available to establish a comprehensive cancer centre in Sydney, to ensure that best practices of research are being translated to patient care.
The increase in incidences of diabetes and its links to obesity have been a major focus of the work of the Department and, with the establishment of the Preventative Health Taskforce,
2 there will be renewed focus of new and possibly different approaches to preventing this complex problem. The taskforce will advise Government on the most effective interventions to combat the high prevalence risk factors of diabetes and vascular disease, obesity, tobacco and alcohol consumption.
We have been working in other important areas of public health, such as providing advice to food ministers of the health benefits of fortification of food with folate and iodine to prevent the deleterious effects of deficiencies of these substances, particularly on the unborn child.
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Indigenous Health
The disparity of health outcomes continue despite the improvements in some chronic disease parameters first reported last year. The solution to ‘closing the gap’ is multisectoral but ensuring a good start to life and reducing the high prevalence of known risk factors have been the focus of our efforts. As part of the Australian Government’s Northern Territory Emergency Response, 9,454 voluntary health checks were delivered to children under the age of 16 who live in the prescribed areas. Oral health issues and ear diseases were the two most prominent health issues identified through the child health checks. Other conditions associated with poor nutrition, housing and hygiene were also detected.
Over the next two years, the Expanding Health Services Delivery Initiative will increase primary health care service delivery, establish a Remote Area Health Corps to increase the supply of health professionals in the Northern Territory, and build regional approaches to service delivery. Teams of surgeons and health professionals from around Australia will be available to provide additional capacities, when and if required.
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Indigenous Health and Sustained Home Visits
The Australian Nurse Family Partnership Program is based on the work of Professor David Olds and his Nurse- Family Partnership Program model and tools developed in the United States. This program has been the subject of several rigorous longitudinal studies that demonstrate significant social, economic and health benefits for participants in this program.
Professor Olds’s model will be adapted to reflect the Australian health care system, the geographic diversity across Indigenous communities and Aboriginal and Torres Strait Islander culture.
The Australian Nurse-Family Partnership Program will reach beyond clinic settings into the home, where positive health behaviours and child rearing practices can best be reinforced into lifelong habits. Health professionals will provide home visiting services to women pregnant with an Aboriginal and Torres Strait Islander child in targeted areas, continuing until the child is two years. Child and family support will be provided to high need children aged 2–8 years in targeted areas.
The program aims to improve pregnancy outcomes by helping women to engage in good preventive health practices, supporting parents to improve child health and development, and helping parents to develop a vision for their own future, including continuing education and finding work.
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Transplantation
There has been a lot of attention by many in the community to try to determine why the rate of Australian transplantation of kidneys, livers, hearts and lungs are low when contrasted with many comparable countries. Those organ transplants performed are done to a very high standard by world standards but, with the low rate of organ donors, many potential recipients miss out. The National Clinical Taskforce on Organ and Tissue Donation came up with 51 recommendations to improve organ donation rates.
Recommendations included: develop and implement an education and awareness campaign targeted at Aboriginal and Torres Strait Islander peoples; promote the central importance of the Australian Organ Donation Register in an integrated communications strategy; establish a national trigger mechanism for the early identification of potential organ donors in all intensive care units and emergency departments; and establish a national authority to coordinate reform efforts. A national committee that I chair was asked by ministers to bring forward proposals on how to implement these recommendations. The committee has commenced work and will bring forward recommendations to implement national protocols in respect of paired kidney exchanges, donation after cardiac death and clinical triggers.
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Rural Health
The relative health disadvantages of people living in rural and remote areas of Australia continue to be a problem. There are less services available due to fewer health professionals, therefore diagnosis is often delayed and treatment inconvenient or inaccessible. This particularly applies to maternity services. There has been a legion of attempts to address these problems in the past. The Office of Rural Health has been established to bring together these programs and explore how to best achieve equitable health care for this sector of the community.
On 30 April 2008, the Minister for Health and Ageing announced the establishment of the Office for Rural Health. During its first year, the Office of Rural Health will review all rural health programs to ensure that they are meeting the needs of rural health professionals and rural communities. Additionally, the Department will review the classification systems that determine eligibility for rural programs to ensure that workforce incentives and rural health services respond to current population figures and areas of need.
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Communicable Disease
June to August 2007 was particularly bad for seasonal influenza. Western Australia and Queensland were hardest hit with a number of infants and children dying. The Australian Health Protection Committee worked collaboratively as usual, under the Chair of Ms Murnane, to monitor the situation and ensure that it was seasonal influenza and not a new emerging disease we were dealing with. The lessons learnt for future years was that our ‘real time’ surveillance was not adequate to manage this situation and the Office of Health Protection is working with state and territory public health units to improve the situation. This year to date the influenza season has been generally mild.
The severity of last year’s influenza season had a significant effect on the residents of aged care facilities, where the congregate living arrangements heighten the risk of transmission. Many facilities were affected, in all states and territories, with a number of deaths attributed to influenza. I highlighted the importance of influenza immunisation for residents in a letter to all general practitioners, and similar advice was provided to aged care facilities. In addition, gastroenteritis was of concern. The Office of Aged Care Quality and Compliance worked closely with the Office of Health Protection to improve infection control in residential aged care.
The risks of mosquito borne diseases continue to be a concern and this year has seen a record number of cases of dengue fever in our northern neighbours and increasing concerns that chikungunya fever may become established in Australia.
3 We have been working with the Australian Quarantine and Inspection Service, and the Queensland and Northern Territory Governments to ensure control of the mosquito populations that are the carrier for these diseases.
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Primary Care
This year saw an increased recognition that we need to support models of shared care that deliver more integrated and coordinated services to patients. For those living with a chronic illness, seeing multiple providers and receiving care in a variety of settings is part of everyday life. This experience can be disjointed and fragmented, and involves navigation through the health care maze. The Australian Health Ministers’ Conference at its meeting in February 2008 identified that work must be done at both the Commonwealth and state and territory levels to bring together the various aspects of the health system. To support this aim, the Department convened a National Integrated Primary Care Workshop in March 2008 which I attended, along with state and territory health departments, stakeholders from across the sector, and also consumer representatives. The workshop provided a forum in which to share information about innovative or successful models in this space, and to discuss the sorts of mechanisms or tools that can be used to improve the integration of primary care in Australia.
The Department is also currently working to implement the GP Super Clinics program. Thirty-one GP Super Clinics have been announced across Australia and the Australian Government has committed a total of $223.2 million, over four years from 2007–08, to the program. GP Super Clinics provide a valuable opportunity to test new models of service delivery in primary care, especially around the prevention and management of chronic disease using integrated, multidisciplinary teams.
On 11 June 2008, the Minister for Health and Ageing announced that a National Primary Health Care Strategy will be developed by Government with assistance from an External Reference Group. By announcing this strategy, a first for Australia, the Government recognises that strong primary health care is central to keeping people well, not just looking after them when they are sick. The strategy will provide a road map for the future direction of primary care in Australia.
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International Issues
International events have always had the potential to impact on health and health service delivery in Australia. A number of events have highlighted how vulnerable we are to these events. Last year Indonesia announced it would cease sharing influenza viral samples with the World Health Organization thereby putting at risk disease surveillance and vaccine manufacture.
Negotiation between all parties continued all year with Secretary Jane Halton chairing the Inter-governmental Working Group, trying to resolve these issues. There has been progress but there is a way to go. If there is no resolution to the problem, the potential risk is the breakdown, not only of global influenza surveillance, but also a loss of information about other infectious diseases and the ultimate failure of the international Health Regulators to have their regulations implemented.
Another serious concern has been the contamination of the anti-coagulant Heparin which is necessary to treat a wide variety of potentially life threatening diseases, so that all Heparin-based products are potentially a risk to patients. In March of this year we were also alerted to the contamination of some products with super sulphated chondroitin sulphate.
It became evident that the majority of contaminated Heparin came from a single supplier, putting the bulk of the world stock at risk. To date, fortunately, there have been no adverse reactions in Australia and at present there is sufficient uncontaminated stock for our clinical needs. The Australian Health Protection Committee working with the clinical colleges and the Australian Medical Association is continuing to manage this evolving problem.
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Conclusion and the Future
The next twelve months will be an important watershed. Many of the important health reforms in the delivery of primary care particularly focusing on the management of chronic disease will be implemented. Along with these reforms there will be an increased focus on prevention across the whole spectrum of disease ranging from national programs on major health issues such as obesity, to how individual Australians at risk are screened for diseases such as diabetes and renal diseases.
These important initiatives will be reflected in changes on how health is delivered by a whole range of health professionals and also how we educate the next generation of health professionals to best deliver health care in a changing environment.
Professor John Horvath AO
Chief Medical Officer
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