Updated AGPA newsletter

Dear AGPA Members

Welcome to a revised version of the AGPA newsletter. Please note you will be asked for your username and password if you click on this item. Your user name is firstnamelastname (e.g. trishbaker) and your temporary password is also firstnamelasatname (eg trishbaker) with no space between them. You can change your password after you log in for the first time. Any problem email admin@australiangpallianace.com.au. Enjoy the improved site. Read more

Should a practice treat its own staff?

A meeting of the RACGP & AGPA on 14 November 2017 covered the vexed issue of whether a practice should treat staff members, other than in an emergency.

The slides from presentations at the meeting can be downloaded here.

W(h)ither general practice? Be careful what you wish for

Dr Ian Kamerman*

Let’s be quite clear. The move by the Department of Health to return general practice training to the colleges is a good thing. This is in fulfilment of their obligation to the Australian Medical Council.

This is, after all, what colleges are supposed to do, and now the general practice colleges will join their fellow specialty colleges.
However, my concern is that this may also signal a reduction in government engagement and its resourcing of general practice training.
What message is government sending? Read more

AGPA Editorial. Australian GPs deliver best outcomes

By Dr Trish Baker

Practice owners update across the profession

• Australian health system delivers best outcomes for lowest cost
• GP numbers swelling
• Patient access issues are now in the past – including rural and remote
• Empty appointments the new challenge for practice owners
• Colleges take back GP training
• 7000 non VR’d doctors to be helped to achieve VR GP status through a Unified Training Pathway

Shout it from the rooftops – Australian GPs are helping deliver the best health outcomes in the OECD with the lowest cost health system!! (Commonwealth Fund data). Talking of pay for performance, we deserve a rise!

The government may have solved its patient access problem by swelling the numbers of GPs but in doing so has created a new challenge for GP city practice owners. How do we fill our appointment books?

High bulk billing rates (a mark of intense competition for patients) (see Govt figures) together with the inadequate Medicare rebate is causing flat or declining practice income, making it tougher than ever to deliver quality care for our patients. As the costs of rents, wages and consumables rise, practice income is declining or flat in most areas across the country.

Dr Ian Kamerman looks at the consequences of the increasing number of doctors, stagnant wage growth among patients, and stagnant government funding for primary health care.

With Medical student numbers at an all time high, we are set to see up to 7000 non VR’d doctors offered assistance to become qualified GPs through a Unified Training Pathway. This initiative should help reduce the high failure rate of (mainly IMG) doctors preparing for the FRACGP without the teaching and support of the Australian General Practice Training program.

Perhaps the silver lining in this changing environment is that quality GP principal led practices, focused squarely on providing better patient care, will attract the best of the new talent. Better health care delivered in a modern, responsive, outward looking but patient centered family practice is surely best for the patient, the GP and full practice team.

Record 85.9 per cent bulk-billing rate

More Australian patients are visiting their GP without having to pay, with the bulk billing rate for the September quarter increasing to a record 85.9 per cent.

This is the highest bulk billing rate ever achieved for a September quarter – and significantly higher than Labor’s 82.2% when they were last in Government, according to Health Minister Greg Hunt.

“We’re spending more than ever before on Medicare – with record funding increasing each and every year from $23 billion in 2017-18, to $24 billion, to $26 billion to $28 billion in 2020-21,” he said. “Spending under Labor was $19.5 billion in 2012-13.

“Last financial year, Australian patients received an additional 21 million bulk billed GP visits compared with Labor’s last year in Government in 2012-13 – an increase of more than 20 per cent.”

Diagnosis creep: people made patients unnecessarily

Australians are increasingly facing ‘diagnosis creep’, where disease definitions are widened and people are unnecessarily turned into patients, experts say.

Dr Ray Moynihan (PhD), senior research fellow at Bond University, said expanded disease definitions were often decided upon by panels muddied by conflicts of interest, and had the potential to be harmful. Read more

$24m: largest heart research grant in Australia

The Federal Government will invest a record $24 million to support landmark research into cardiovascular disease by The George Institute for Global Health. This is National Health and Medical Research Council’s third largest grant ever provided for medical research in Australia and the largest investment in research on cardiovascular disease – a disease which many Australians do not know they have. Read more

Funding for young doctors in rural areas

Hundreds of new junior doctors will experience work as a general practitioner in regional and rural Australia, thanks to the second round of the Federal Government’s Rural Junior Doctor Training Innovation Fund (RJDTIF) announced (Nov 2017). Read more

Child leukaemia progress shows way for brain cancer

David Ziegler, Associate Professor (conjoint), Children’s Cancer Institute
Brain cancers are the leading disease-related cause of death in Australian children. And survival rates have changed little in decades. As a paediatric oncologist, the worst conversation I can have with my patients or their parents is to tell them their tumour is incurable.

Last week, the federal government announced the Australian Brain Cancer Mission, with a A$100 million injection for research to double survival rates and improve quality of life for people living with brain cancer over the next ten years. This is an important step forward.

My hope is that we can replicate for brain cancer what has been achieved for leukaemia. The survival rate for the most common form of childhood leukaemia was once zero but today it’s 85%. To achieve this outcome for brain tumour patients, we will need to adopt a similar strategy as with leukaemia.

Childhood leukaemia treatment

In the first half of the last century, parents whose children were diagnosed with leukaemia were told to take them home to die. Then chemotherapy was introduced. In the early 1940s, the first chemotherapy trial in children used a drug called aminopterin, which suppresses the immune system.

In November 1947, Dr Sidney Farber, a pathologist at Children’s Hospital in Boston, discovered that aminopterin had a potent effect on leukaemia cells growing in the test tube. He tested aminopterin in 16 children with leukaemia and obtained temporary remission in ten of them. While this provided a glimmer of hope, it wasn’t a cure. After the treatment stopped, the cancer always came back.

Aminopterin has a potent effect on leukaemia cells growing in a test tube. from shutterstock.com
A major breakthrough came in 1965 in the US with a combination of four drugs – vincristine, prednisone, methotrexate and 6-mercaptopurine – known as VAMP. These drugs all have different mechanisms of action and together were shown to induce long-term remissions in children with acute lymphoblastic leukaemia (ALL) – the most common form of childhood leukaemia.

Today it is a generally accepted rule of cancer treatment that drugs are more effective in combination than as single agents. In the period 1965-1979, childhood leukaemia death rates in the US fell 50% due to improvements in therapies like this, as well as other ongoing developments.

Read more: What is chemotherapy and how does it work?

Leukaemia lessons

The significant advances in the treatment of paediatric ALL have come, in large part, from the high participation rate of patients in clinical trials. But there are several other lessons that will help in our battle against brain cancer.

First, the initial and crucial discoveries in leukaemia treatments were made in the laboratory, using models that reflected the disease in humans. Until recently, these models have been lacking for paediatric brain tumours.

Second, leukaemia was not cured with any single magic bullet. Combination therapy made a radical difference to success rates.

Today children with leukaemia are cured by using intensive treatment with 10 to 12 different chemotherapeutic agents. Given brain cancer is even more aggressive than leukaemia, it is likely potent combinations will be needed to make a difference in outcomes.

Third, there was a seamless transition from the lab to clinical (human) trials in leukaemia. It was the same researcher running the laboratory who took his or her discoveries and started treating their own patients.

Read more: Childhood cancer deaths have fallen in Australia, but some types remain more of a challenge

Difficulties in brain cancer

Brain tumours may occur in or near critical areas of the brain. For instance, these areas may control speech, movement or even breathing, making surgery risky or impossible.

The most aggressive cancer in children is a type of brain tumour called Diffuse Intrinsic Pontine Glioma (DIPG), which remains completely incurable. Its sensitive location in the brainstem means the tumour cannot be removed surgically. Even biopsies are usually not performed.

Patients don’t respond to chemotherapy. The only standard therapy is radiation, which only temporarily delays disease progression. Most children do not survive more than one or two years after diagnosis.

Brain cancer is difficult to treat because of the sensitive location of the tumours. from shutterstock.com
Even if drugs can be shown to work in the lab, a major challenge for drug treatments for brain cancers is the blood-brain barrier, a membrane that protects the brain from toxins but also stops access for many anti-cancer drugs. Very few drugs can make it across the barrier from the bloodstream to reach tumours. In tumours like DIPG, it seems the blood-brain barrier is particularly tight.

Read more: What is the blood-brain barrier and how can we overcome it?

What we need to do

One issue that has hampered medical research into childhood brain cancer treatments is a lack of tissue samples. Farber easily obtained leukaemia cells from the blood of his patients, which was central to making his discoveries. Collecting samples from brain tumour patients is much more risky and until recently had been considered impossible.

To address this my team started a donation program for parents to donate their child’s tumour after a child has died. We are also learning how to safely biopsy DIPG tumours. We have obtained 31 tumour samples to help investigate DIPG’s genetics and biology and to test potential treatments.

This is part of a global initiative that owes its existence in large part to the generosity of parents wanting to help other families. We have used this resource to screen more than 3,500 drugs, in one of the largest DIPG drug screens. As a result, we have identified five active drugs that cross the blood-brain barrier and have anti-DIPG activity.

We have also performed screens looking at thousands of different drug combinations to identify further active therapeutic strategies.

Funding for brain tumour research will help ensure discoveries made from efforts like this can be rapidly translated to clinical trials to help children who need new treatment options. To achieve this, it is critical that funding goes to support intensive laboratory research, as well as the clinical trial infrastructure needed to bring these discoveries directly to the patients.

Last but not least, personalised medicine holds great hope for children with brain cancer, offering the opportunity to exploit each tumour’s distinctive molecular and genetic features. We have conducted a pilot personalised medicine study for Australian children with high-risk cancers, through the Zero Childhood Cancer program led by the Children’s Cancer Institute and Sydney Children’s Hospital, Randwick.

About half the children in this study had brain tumours – highlighting that this remains a critical area in need of more research and new treatments.

Read more: How cancer doctors use personalised medicine to target variations unique to each tumour

In mid-September, we opened a national clinical trial that will enrol up to 400 children with high-risk cancers over the next three years. We expect children with brain cancers will be one of the biggest groups of patients on the trial.

We hope the program will not only help individual children but that lessons learnt from the trial will be used to discover and test future treatments for brain cancer, boosting survival further.

NZ: reducing GP fees not so simple

In the recent New Zealand election campaign, one policy united parties from all parts of the political spectrum – their intention to reduce the fees patients pay for GP practice services. The only difference was by how much fees were promised to fall and which groups within the community would benefit from increased subsidies. Read more