HealthSpeak Spring 2015

HealthSpeak the voice for health professionals – from tweed to port macquarie

Child Protection It’s everyone’s responsibility

issue 13 • spring 2015

page 25

6

Multidisciplinary OA program

15 Building cultural bridges

17 Trauma Informed Care

24 Skin Cancer Fact Sheet

Health workers and child protection Head Office Suite 6 85 Tamar Street Ballina 2478 Ph: 6618 5400 CEO: Vahid Saberi Email: enquiries@ncphn.org.au Hastings Macleay 53 Lord Street Port Macquarie 2444 Ph: 6583 3600 Cnr Forth and Yaelwood Sts Kempsey 2440 Email: enquiries@ncphn.org.au Mid North Coast 6/1 Duke Street Coffs Harbour 2450 Ph: 6659 1800 Email: enquiries@ncphn.org.au Northern Rivers Tarmons House 20 Dalley Street Lismore 2480 Ph: 6627 3300 Email: enquiries@ncphn.org.au

editor Janet Grist

W

hen I was approached to write a feature for HealthSpeak on child protection, I knew little about the

Contacts Editor: Janet Grist Ph: 6622 4453 Email: media@ncphn.org.au Clinical Editor: Andrew Binns Email: abinns@gmc.net.au Design and illustrations: Graphiti Design Studio Email: dougal@gdstudio.com.au Display and classified advertising at attractive rates HealthSpeak is published four times a year by North Coast Primary Health Network. Articles appearing in HealthSpeak do not necessarily reflect the views of the NCPHN. The NCPHN accepts no responsibility for the accuracy of any information, advertisements, or opinions contained in this magazine. Readers should rely on their own enquiries and independent professional opinions when making any decisions in relation to their own interests, rights and obligations. ©Copyright 2015 North Coast Primary Health Network Magazine designed by Graphiti Design Studio Printed by Quality Plus Printers

HealthSpeak is kindly supported by

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any suspicions of child abuse or neglect.

Doctors know whether parents have a mental illness, abuse alcohol or other substances and are fit to properly care for a child. They might well be able to provide a vital piece of information.

Please take the time to read the feature on page 25. Remember, it’s everyone’s responsibility to keep children safe.

Spring is in the air

Tweed Valley Unit 4, 8 Corporation Circuit Tweed Heads South 2486 Ph: (07) 5523 5501 Email: enquiries@ncphn.org.au

Health Speak

subject. It was alarming to find out that during 2013/14 more than 7200 children were found to be at significant risk of harm on the North Coast – and even more disturbing to discover that reports of suspected child abuse are not commonly made by GPs and other health professionals.

And yet GPs are the professional most likely to know what’s going on in a family and it is their legal duty to report

ceo Vahid Saberi

L

ife is about relationships.

Relationship with our family, our garden, our neighbours, our dog and our barista! Success in the reform of the health system equally depends on relationships and partnerships. It is well recognised and documented that unprecedented financial and service pressures in health care will not be addressed without effective collaboration.

I wrote about the elements that were necessary, based on our experience, to bring about change in the health system in the summer 2015 edition of HealthSpeak. The bedrock of building a culture of collaboration, which is critical for change, is trust, goodwill and commitment. Trust and goodwill provide the rich soil in which the seed of collaboration germinates and grows. This trust and goodwill is also the safety-net as we walk the tightrope of collaboration; without which we would be hurt and traumatised if we fall.

In the past year, I have been thinking deeply about the concept of collaboration. I am

convinced that little will be achieved without meaningful and authentic relationships. I use the word ‘authentic’ intentionally.

There is much in the literature about authenticity in relationships. Where there are no hidden agendas, the relationship is genuine and sincere. The wellbeing of one partner is the wellbeing of the other, resulting in real interdependence. Genuine and sincere relationships will not just result in better outcomes for the community, but also more fulfilment for those working together to achieve those goals.

We have observed and learned some key elements about building partnerships between organisations to bring about lasting change. For real lasting change partnerships need to take place at three different levels.

The first is at the level of the Board and senior management.

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The governing Boards of the organisations need to be committed to engaging with each other – this is the foundation to strong partnerships. This equally applies to the senior management (CEO and Executive). We see this akin to the ‘root’ of a tree – the root of the partnership.

The next level is what we call the ‘trunk’ of the partnership.

This is the alignment of the systems and structures of the organisations. This includes cross-membership on appropriate committees such as clinical councils, community advisory structures, quality committees, planning processes and so forth.

And then there are the partnerships at the level of services and programs. This is akin to the ‘leaves and the fruit’ of the tree.

Without the trunk and the root, achieving great outcomes here is challenging.

There are a few other things we have come to appreciate along the way. Partners must consider each other as equals; value contributions, no matter how small; share successes; be open and transparent; have each other’s back in the face of criticism; and raise and resolve issues quickly.

So with Spring in the air, it is the time for seeds to germinate, roots to strengthen, trunks to thicken, flowers to bloom and fruit to grow in collaborations for health system change. healthspeak Spring 2015

Childhood trauma can trigger later life obesity M

any obese/morbidly obese Americans have been identified as suffering physical, sexual or verbal abuse, or other adverse trauma, in their childhood, according to a milestone study by the US Centers for Disease Control and Prevention (CDC).

The Adverse Child Experience (ACE) Study1 found that living with an alcoholic or drug taking parent or a mentally ill family member, or experiencing rape or other physical assault, can also be triggers for weight gain in later life (as well as other chronic diseases).

The prevalence of this connection is only starting to be recognised by clinicians, including GPs and counsellors, with presentations suggesting that the Australian experience parallels that of the USA. It is estimated from this study and other data that about 8 per cent of obese people were sexually abused as children. It is well known that food, like the more evidently harmful tobacco and alcohol, can offer comfort by temporarily relieving stress, bad memories, shame or guilt.

This applies even when obesity becomes uncomfortable or even life threatening. Yet many people who are obese still look at eating as a solution not a problem. For these unfortunate people our well intentioned advice on diets, nutritional advice or increasing exercise may fall on deaf ears and be unhelpful.

It is worth noting that for obese people who did not have childhood trauma, conventional weight loss measures involving nutritional and physical advice, or even bariatric surgery for more severe cases, are more likely to play a constructive part in a wellness pathway. That said, there are many reasons for Spring 2015 healthspeak

obesity, although ACE is a more common one than previously recognised.

The research began in 1985 when Vincent Felitti, the chief physician of Kaiser Permanente’s Department of Preventive Medicine in Dan Diego, was puzzled as to why 55 per cent of the 1500 people who enrolled in his weight loss clinic every year left before completing the program.

Most had been losing weight when they dropped out.

Dr Felitti interviewed 286 of these patients and found a pattern showing most had gained significant amounts of weight quite quickly at about the time they became sexually active.

They may have then stabilised their weight, and even if they lost weight they regained it quickly, sometimes exceeding what they had originally lost.

In 1990, he presented his findings to the North American Association for the Study of Obesity in Atlanta. The study was denigrated by members who told him he was naĂŻve to believe his patients.

However, Dr. David Williams, then a CDC researcher, was intrigued and advised him in the interests of credibility to do a much larger study on the relationship between childhood trauma and obesity, and introduced Felitti to Robert Anda, a medical epidemiologist at the CDC. Dr Anda took six months to research 15 years of child abuse literature, and selected 10 risk factors to measure.

Along with physical, verbal and sexual abuse, and physical and emotional neglect, five other factors seemed significant. These were having a parent who

was an alcoholic or diagnosed mentally ill, a family member in prison, a mother who was being abused, and losing a parent through abandonment or divorce. Anda and Felitti decided to call their research the Adverse Childhood Experiences Study (ACE Study).

The research was done in 17,000 mainly white, middle and upper class people most of whom had jobs and education.

They concluded ACEs were a major determinant of many chronic diseases, not just obesity, and this is a major public health impact that will be the topic of a future article.

clinical editor Andrew Binns

Many people who are obese still look at eating as a solution not a problem

To find out about the most appropriate approach to treating victims of abuse, see Mim Weber’s article on Trauma Informed Care on page 17.

(1) http://www.cdc. gov/violenceprevention/acestudy/ Further reading: http://acestoohigh. com/2012/05/23/ toxic-stress-fromchildhood-traumacauses-obesity-too/

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Mental Health Integration: third phase O

n June 3 in Ballina, a Regional Planning Forum was held as the final phase of the Mental Health Integration Strategy signed in 2013 by the Northern NSW Local Health District and North Coast Medicare Local.

Ninety representatives from 39 offices of North Coast mental health agencies, as well as consumers attended to develop actions for the priorities identified in phase one of the strategy, the online survey.

From this survey a vision statement for the Strategy was developed: “People and communities with mental health concerns are on a seamless journey of recovery, toward lives characterised by meaning, connection and contribution, served by a network of integrated, coordinated and collaborative care.”

The survey identified the following priorities: Care Navigation; Stigma Reduction; Multidisciplinary Teams and Information Sharing Systems.

The second phase was the holding of 27 focus groups made up of agencies and consumer groups whose opinions were heard on various perspectives of mental health and wellbeing, collaborative efforts to date, regional priorities and systemic and social issues around mental health.

These focus groups indicated a fragmented and siloed industry with poor trust and cohesion between services, issues consistent with the findings of the National Mental Health Commission’s review into mental health services. Of significance was the inability to understand the landscape of competing services; the over-emphasis on referring; the frustration of communication and follow-up; and accepting risk and responsibility for consumers.

Information from the focus groups relevant to the four priorities was then mapped. The June Forum was held to develop 4

Shared Information Systems Actions Goal: Seamless, streamlined

system of communication for consumers and services. Strategies: Consumer-led information sharing, advance care directives; united information sharing policy. Outcome: A working committee self-nominated to take this priority further.

A working group at the Mental Health Integration Strategy Planning Forum in June.

actions for the four priorities.

These were: Care Navigation Goal: Person-centred approach to learning; Strategies:

Common documentation and guidelines; centralised database of client information, consent and plan; shared definitions for collaboration; systems for building relationships and networking; employing peer workers; co-location of services.

Outcome: A steering committee has self-nominated to work on this priority.

Stigma Reduction Goal: Mad Pride Festival;

school and TAFE and family education. Strategies: Role models, mental health ambassadors; mental health play at schools; mental health show bags at rural events. Outcome: Individuals self-nominated to initiate these recommendations.

Multidisciplinary Team Actions Goal: Service Hub, education and awareness. Strategies:

Model on existing examples; identify stakeholders; cross pollination from services; database

of services, regional training.

Outcome: Email lists are available to create a working group.

A Northern NSW Mental Health Integration Plan is being developed and a draft plan will become available for comment.

A governance structure for the plan will also be formalised. It is envisaged that the Regional Forum will be held annually.

For more information, contact Michael Cohen at NCPHN on 02 6618 5425 or email mcohen@ncphn.org.au

Mandatory reporting of child abuse The law requires that health professionals report suspected child abuse. If you have reasonable grounds to suspect that a child is at risk of significant harm you must report it. Under the law you are protected from prosecution if you make a child abuse report in good faith. You do not need to establish that child abuse is occurring, just report your suspicions and FACS will investigate.

You can make a report by phoning the NSW Family and Community Services (FACS) Child Protection Helpline on 133 627. Mandatory reporters are encouraged to use the Mandatory Reporter Guide.

You can find the Guide here: http://sdm.community.nsw.

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gov.au/mrg/screen/DoCS/ en-GB/summary?user=guest The HealthPathways website has also set up a referral pathway for reporting child abuse. It’s at: https:// manc.healthpathways.org. au/88091.htm The username is manchealth and the password is conn3ct3d Read the Child Protection feature on page 25 to find out what to look for in a child you suspect is being abused and the main ‘at risk’ situations.

healthspeak Spring 2015

headspace launch attracts a crowd T

he evening event was a great success with hundreds of people coming along to show their support for youth mental health. Visitors enjoyed a range of activities on offer, including live local musicians, self guided tours of the premises, a free BBQ, multicultural performances, a photo booth, fire twirling and more.

An event committee was formed from the youth sitting on the headspace Tweed Heads Youth Advisory Group (YAG). These young people took lead in organisational roles over three busy months leading up to the opening launch. The event focussed on mental health awareness and education with speeches from North Coast Primary Health Network CEO Vahid Saberi and headspace National Office

The headspace Tweed Heads centre was packed to capacity in late June when staff hosted the official launch.

representatives. headspace Tweed Heads YAG members Keiah Smith and

Renee Cashmere-Simpson also talked about their experiences of mental health difficulties

and explained how headspace had helped them. Educational information on mental health was shared through tours of the Centre with mental health simulation headphones, laughter yoga, art therapy and info booths.

A big thank you to everyone who helped to ensure the success of the event. Special thanks to Banora Point High School, The Family Centre, The Domino Effect and Owen Mitimeti for their contributions, as well as to local businesses and individuals for their raffle donations and volunteers who helped everything run smoothly.

After such a fun and interactive launch, staff say they are looking forward to celebrating headspace Tweed’s first birthday next year.

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New approach to effectively treat OA G

Ps from five Mid North Coast general practices and two general practices in the Hastings Macleay region have teamed up with allied health services to take part in a project to evaluate the effectiveness of a care coordination program for osteoarthritis.

North Coast Primary Health Network (NCPHN), Mid North Coast Local Health District and the NSW Agency for Clinical Innovation (ACI) are jointly running the project, the Primary Care Osteoarthritis Program (PCOAP).

The Program is based on evidence demonstrating that OA is best managed through a management plan that suits the individual needs of the patient.

A number of GPs from Urunga Medical Centre, Three

The multidisciplinary workgroup at Beach St Family Practice, Woolgoolga. From left, standing: Sam Dixon, Physio MNC Physiotherapy; Aaron Hardacker, Physio MNC Physiotherapy; Dr John Kramer GP; Sally McCann, Practice Nurse; Dr Judy Haines GP; Lee Hayes, Practice Manager; Sitting from left: Dr Genevieve Halligan GP registrar; Alex Brugisser, Exercise Physiologist, MNC Physiotherapy; Sheree Riley, Dietician, Coffs Coast Nutrition.

Rivers Health in Bellingen, Coffs Medical Centre, Coffs Central Medical Centre, Beach Street Family Practice in Woolgoolga,

Port Macquarie GP Super Clinic in conjunction with Keystone Physiotherapy and Allied Health Services and Campbell

New business model for Tarmons

T

armons House Mental Health Service (THMHS) in Lismore run by North Coast Primary Health Network has commenced a new service model to ensure the sustainability of the service.

For clients without a Pension or Health Care Card, there will be a co-payment of $50 per session. This fee may be waived or reduced at the discretion of the clinician.

THMHS offers a variety of disciplines including clinical psychologists, registered psychologists and mental health social workers. Referrals to Tarmons should be faxed to 02 6621 7082. Faxing referrals rather than giving them to the patient streamlines the referral process.

All Tarmons mental health professionals are contracted to deliver Healthy Minds services. Healthy Minds provides

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Tarmons House Mental Health Service in Lismore

free mental health services for people who have an Australian government Health Care Card or those suffering financial distress. Healthy Minds target groups include people form low socioeconomic backgrounds, children and people at risk of suicide, and Aboriginal and Torres Strait Islander people. Referrals to Healthy Minds should be faxed to 02

6627 3396.

Under the new model, Tarmons’ outreach services in Ballina and Casino will fall under Healthy Minds. You can refer to Jill O’Brien in Ballina and Angela Andrews in Casino by fax to 02 6627 3396.

If you have queries about the new model, contact Vickie Williams on 6627 3302.

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Street Surgery at Wauchope in conjunction with Wauchope Physiotherapy have volunteered to partner in the project. The GPs will work together with physiotherapists, exercise physiologists and dieticians to deliver this program to patients.

Professor Lyn March of ACI said intervention measures could make a real difference.

“Controlling weight is important for those who have osteoarthritis in hip and knee joints, and the right type of exercise can keep the joints mobile and maintain or improve function.

Movement also improves muscle strength and maximises the health of the cartilage,” she said.

Dr Warwick Yonge from the Port Macquarie GP Super Clinic said the clinic was delighted to be involved.

“High quality coordinated primary care involving allied health professionals and GPs is the best way of reducing expensive and traumatic treatments such as hip and knee replacements. It is a win for patients and the community,” he said.

Over 10 years, the number of knee and hip replacements has risen by 47% and 17% respectively. The PCOAP aims to minimise the suffering and disability of OA and to keep people away from the surgical waiting list by acting early.

Dr David Gregory of the North Coast Primary Health Network said that as the North Coast Medicare Local transitioned to the new Primary Health Network this partnership represented a new focus on commissioning services to meet patient needs and working together with other parts of the health system to improve patient outcomes.

“It’s a great example of how North Coast Primary Health Network can create partnerships to provide high quality specialized care for patients at the right place at the right time,” he said. healthspeak Spring 2015

Flu vax reduces risk of MIs

New NCPHN Board member

N

A

meta-analysis of 16 international studies has shown that a yearly flu vaccination reduces the risk of myocardial infarction to the same degree as other secondary preventions, and potentially even more.

Lead author Professor Raina MacIntyre from the University of NSW is now calling for vaccinations to be given to all patients over the age of 50.

The researchers found that those recently infected with the flu had double the risk of acute myocardial infarction compared to those not infected. In addition they found that vaccination conferred a 29% risk reduction of acute MI. This is comparable to the reduction produced

for smoking cessation (26%), statins (25%) and anti-hypertensives (18%).

Professor MacIntyre says universal vaccination for those over 50 could have a substantial public health impact.

“The flu vaccine is safe, effective and is not expensive. Based on this study’s findings, anyone over 50 should consider getting vaccinated, especially if they are at risk of heart disease,” she says.

“Even if you’re a healthy weight and you’ve no family history of heart attacks, you may have some thickening of your arteries without knowing it.”

orth Coast Primary Health Network’s Board of Directors has a new member.

Dr Joanna Sutherland replaces Ms Sheila Keane, who has departed the Board after three years of diligent service Jo is a specialist anaesthetist in Coffs Harbour, with a Masters of Health Policy, and a research Masters of Clinical Science.

Up to now, extending flu vaccination programs to 50 to 64 year olds has debated, it has not been considered to be cost effective. Yet prevention of cardiovascular disease wasn’t taken into consideration, Professor

She is actively involved in teaching and training medical students as a Conjoint academic with the UNSW Rural Clinical School.

She also trains and supports specialist and GP anaesthetists.

Also a member of the Mid North Coast Local Health District Governing Board, Jo is committed to enhancing the integration of health systems and services.

MacIntyre notes.

The study is the first metaanalysis of the impact of influenza on acute MI, one of the leading causes of death worldwide. It was published in Heart 2015; online 27 August.

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For further information please call 1300 763 583 Shelly Fletcher eHealth and Primary Care Manager Kelly Anderson eVillage Telehealth Registered Nurse

Spring 2015 healthspeak

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7

Workgroups & developing diabetes HealthPathways

D

iabetes is a national health priority with 280 newly diagnosed type 2 patients every day. The early identification and optimal management of people is critical and GPs play a central role in this.

The need to develop regional diabetes Pathways was identified to help with the huge impact of diabetes in primary health care.

Developing HealthPathways for this specialty will provide GPs, specialists, hospital clinicians and allied health professionals with evidenced-based best practice for assessing, managing, diagnosing and treating diabetes.

Each HealthPathway will provide a referral pathway suitable to the patient’s needs and locality, listing available services and programs. The development of these pathways will make navigating the health system easier.

The first Diabetes workgroup to develop a suite of Diabetes HealthPathways was held in August at Tweed Heads.

What is a workgroup?

GPs, specialists and other key providers work in small facilitated groups for three to four 90-

everyone gets their say but not their way – consensus is important.

Workgroup membership

Standing from left: Dr Abhay Daniel, Physician/Endocrinologist, The Tweed Hospital; Dr Austin Sterne GP, Tweed Health for Everyone Superclinic; Dr Dan Ewald, Clinical Advisor NCPHN; Sitting from left: Dr Tim Peacock, Clinical Editor, NCPHN; Shelley Jedrisko, credentialled Diabetes Educator, Tweed Community Health; Cassandra Ebenstreit, Dietitian, Murwillumbah Community Health; Julie Aitken, Diabetes Nurse Practitioner, Tweed Health For Everyone Superclinic; Dr Bob Meehan, GP.

minute sessions to iron out the bugs in issues affecting primary and secondary/specialist care.

Workgroup meetings are held in towns across the region.

areas of service and practice that can be described through a localised HealthPathway model and areas that require service redesign.

Objective of a Workgroup

Workgroup Functions

Through facilitated discussion, workgroups Identify issues affecting the ability of primary and secondary/specialist clinicians to deliver optimum patient care.

The workgroup will identify

Tweed’s NAIDOC Sports Day

A

round 200 community members visited North Coast Primary Health Network’s (NCPHN’s) stand at Arkinstall Park at Tweed Heads on July 8 during the NAIDOC Sports Day. The festivities had a health focus and the NCPHN stall offered interactive activities and competitions offered for youngsters, teens and adults.

In addition to a display warning about the amount of sugar in popular drinks, there was a health quiz, a community health survey which people filled in on iPads, a colouring in table for kids

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and fruit to giveaway.

NCPHN’s Susan ParkerPavlovic said the brainshaped stress balls were an effective conversation starter and the possibility of winning a colourful NAIDOC shirt or bag for entering the health quiz attracted many entries.

To encourage people to participate in the health survey, every entrant had the chance to win a first aid kit. There were also prizes for colouring in and labelling fruits and body parts correctly.

For more NAIDOC stories see Koori Grapevine p20

1. Bring together primary/

community and secondary/ specialist care clinicians; working as one health system.

2. Identify issues affecting each party’s ability to deliver optimum patient care including what currently works well and does not work well; in essence, what are the problems worth solving?

3. Facilitate agreement on consistent care across the combined Local Health Districts/NCPHN footprint; reducing inequity of care caused by clinical variation.

4. Propose solutions to identified issues 5. Contribute to the ‘workup’ of proposed solutions including outcomes.

6. Act as a channel for twoway communication with colleagues and stakeholders to increase awareness of HealthPathways and ensure adequate consultation to inform pathway design;

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The workgroup typically consists of a clinical advisor, clinical editor, general practitioners, specialists, nurses, other health professionals. Senior representation – Clinical Director, Head of Department and Service Manager should be present. Meetings are run by an experienced Facilitator and organised and coordinated by a HealthPathways Project Officer.

Work groups currently underway: Antenatal – Tweed

and Lismore; Drug & Alcohol – Lismore; Mental Health – Lismore; Diabetes – Lismore; Renal – Lismore; Dementia – Ballina; Paediatric – Port Macquarie; Cancer – Coffs Harbour; Antenatal – Coffs Harbour; Cardiology – Port Macquarie.

Diabetes educator Shelley Jedrisko is a member of the Tweed Diabetes Workgroup. She is finding being part of a workgroup very rewarding.

“It’s great to liaise with a variety of health professionals and work on the Pathways knowing they will be helpful in linking quickly to reliable information between services,” she said.

How to become involved

If you would like to be part of a workgroup, contact the HealthPathways Project Officers or register on the HealthPathways website via the Getting Involved section on the home page and selecting the Join a Pathway Development team link.

We will be formulating a Mental Health workgroup in Port Macquarie, primarily to look at depression and anxiety pathways. Please register if interested.

Further information: Kerrie Keyte: kkeyte@ncml.org.au or Fiona Ryan: fryan@ncml.org.au healthspeak Spring 2015

Co-location pilot a success, but more work needed

B

etween April 2014 and 2015, a co-location pilot project involving community health professionals being placed in 11 North Coast general practices took place.

Run as a partnership by North Coast Primary Health Network (or North Coast Medicare Local as it was then) and the Northern NSW and Mid North Coast Local Health Districts, four co-located practitioners worked within the 11 practices. They were two nurse practitioners (chronic kidney disease and chronic cardiac and respiratory disease) from NNSWLHD and two clinical nurse specialists in respiratory failure and asthma employed

by MNCLHD. Over the 12 months, the four co-located practitioners delivered 294 consultations through 77 clinics to 217 patients.

The project wanted to improve the patient experience of receiving multidisciplinary care and the integration of care from the patient and clinicians’ perspectives and wanted to also see the transfer of skills between the community health professionals

The patient had a much quicker referral process, resulting in a correct diagnosis

and the general practice team.

In addition, the project was set up to test the feasibility of partnership arrangements between community health professionals and practice staff, including arrangements for team care plan reviews and case conferencing An evaluation of this innovaSpring 2015 healthspeak

Staff at the Subbiah Family Practice in Port Macquarie, one of the practices that took part in the pilot project. From left, Kerry Gardiner, practice admin; Maree Kennedy RN, respiratory educator; and Dr Nandini Subbiah.

tive project by researchers from Southern Cross University found that at the service delivery level there were high levels of satisfaction with co-location among patients, co-located practitioners, GPs and practice staff.

North Coast Primary Health Network’s Strategic Development and Program Design Manager Sharyn White said that the trial showed that colocation provided patients with convenient, accessible services and improved coordination of patient care.

In one example given to the evaluators, “…a diabetic lady [was referred to the co-location practitioner], the doctor thought she had respiratory problems, but the co-location practitioner assessed her and noted cardiac symptoms. She was referred to a specialist where it turned out to be cardiac instead of respiratory, so the patient had a much quicker referral process, resulting in a correct diagnosis.”

Sharyn said that the evaluation also found that more work was required to quantify the costs and benefits to the practice and the clinicians working in this setting.

“The investigators recom-

mended that we do more work to investigate, clarify and build on the processes that participants came up with at the local level to implement the pilot. They also recommended that we look at

ways to create change at the systemic level, in order to stimulate a deeper and more widespread approach to integrated care within the local primary health care system,” she added.

North Coast Primary Health Network wishes to thank the Northern NSW and Mid North Local Health Districts and the four specialist practitioners who took part and the 11 general practices in which they were located.

The practices were Mulllumbimby Medical Centre; McKid Medical Centre, Kyogle; Tintenbar Medical Centre, Bullinah Aboriginal Health Service, Dr West Casino; Dunoon Medical Centre; Goonellabah Medical Centre; Nimbin Medical Centre; Coffs Medical Centre, Mount View Medical Centre, Laurieton; and Subbiah Family Practice at Port Macquarie.

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The Winsome welcomes its new GP O

n August 12, Dr Timon Jansen from Goonellabah Medical Centre commenced his first morning session at The Winsome Health Outreach Clinic on August 12. Tim was ably assisted by nurse Bronwyn Browne from NNSW LHD. NCPHN was delighted to hear from Tim when he replied to an article in HealthSpeak about the need for a GP to staff the clinic for the disadvantaged at the old Winsome Hotel, now the Lismore Soup Kitchen.

And there are more causes for celebration with the new purpose built clinic room on the ground floor now open. Previously the clinic was held in an old hotel room on the first floor with patients waiting in a lounge nearby. It didn’t provide much privacy or convenience for those wishing to see the doctor.

But now the ground floor clinic is open and it’s been beautifully refurbished. The Winsome Clinic was founded on a collaborative partnership between North Coast NSW Medicare Local, The Winsome/Lismore Soup Kitchen, Northern NSW Local Health District and the St. Vincent de Paul Society (Vinnies).

The Clinic operates once a week for up to two hours on a Wednesday and offers health services free of charge to residents and clientele of The Winsome. It is coordinated by Jane Conway, an NCHPN Program Officer who works closely with the Homeless Outreach Worker Bryan Jamieson from Vinnie’s, to run the clinic. An interagency Working

From left: Jane Conway, NNSWLHD nurse Bronwyn Browne and Dr Timon Jansen on their first day in the new clinic.

Thanks CSL Residents and clients at The Winsome benefited this winter from the kind donation of 40 flu vaccinations by manufacturer bioCSL. The vaccinations were given to residents through The Winsome GP Clinic and disadvantaged people who may otherwise have missed out on a flu vax were able to get one at a place they were familiar with and comfortable with visiting.

Winsome general manager Paul Murphy and Vinnies’ Outreach Worker Bryan Jamieson are thrilled with the refurbished clinic.

Group meets regularly to provide advice regarding the development, operation and long term sustainability of the Clinic.

NCPHN would like to thank Dr Charles Hew, registrar Dr Robert Boyd and nurse Bronwyn Browne for providing GP and clinical nurse services to the clinic. Thanks, too, to Dr Michael Douglas and Dr Tony Lembke who have stepped in to staff the clinic this year.

During 2014/2015, the Winsome Clinic provided 168 GP occasions of service and 124 Community Nurse occasions of service to 65 patients.

Evaluation: PN home visits trial

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year-long trial involving eight general practices on the North Coast examining the potential role for practice nurses to visit patients with chronic health conditions ended in March. In a final evaluation report, it’s been recommended that more detailed analysis around several issues would need to be done before the trial could be progressed further.

The trial was conducted by North Coast Medicare Local (now North Coast Primary Health Network) and Southern Cross University, headed up by researchers Dr Susan Nancarrow and Dr Alison Roots from the 10

School of Health and Human Sciences.

The practices that took part were Mullumbimby Medical Centre; McKid Medical Centre, Kyogle; Union Street Family Practice, Maclean; Tintenbar Medical Centre; Coffs Medical

Centre; Urunga Medical Centre; Beach Street Family Practice, Woolgoolga and Mount View Medical Centre, Laurieton.

Over the 12 months, the practices provided 421 home visits in total and individual survey responses were received from 66 patients. The evaluation found that GPs organised the majority of visits (58%) to older women with a mean age of 82 years. The primary outcomes of the visits were patient reassurance (35%), medication changes or provision (28%) and dressing changes (19%).

In nearly a quarter of visits, the nurse thought the visit had

a publication of North Coast Primary Health Network

prevented the patient from making use of emergency services.

Patients and practice staff were highly satisfied with the service, however, the study also found that there was some duplication or augmentation of existing services and that the gaps in service were poorly defined and understood.

As mentioned above, it was recommended that further analysis would be required to address making access equitable across the region and to avoid the risks of duplication and cost shifting.

There were also the administrative difficulties of managing

Continued page 35

healthspeak Spring 2015

Wellness Day extends its reach F

or over a year North Coast Primary Health Network’s Closing The Gap (CTG) team in Coffs Harbour has been running monthly Wellness Health Information Days at Bowraville in partnership with Ngambaga Bindarry Girrwaa Aboriginal Community Service Inc. These monthly gatherings are held to provide health information to the Aboriginal and Torres Strait Islander community of the Nambucca Valley in an informal atmosphere.

The one-hour information sessions are led by health educators who provide information on their topic, practical solutions to improve health and answer questions. The session is followed by lunch and yarning.

Closing the Gap Project Officer Helen Lambert told HealthSpeak that so far the program

Happy participants at the first Jagun Wellness Day July where the topic was Self-Management of Diabetes.

has covered topics including diabetes, vision, hearing, foot care, dementia, falls prevention, nutrition, cancer, cardiovascular disease, renal and respiratory health.

Helen said that the Jagun Elders from Moonee Beach, just north of Coffs Harbour, had

Meet Fred’s Place staff

heard positive things about the Bowraville program and took a bus trip to the town to be part of a monthly Wellness Day there.

“The Elders enjoyed their Bowraville experience so much that their CEO met with me to request a similar group be held in the Coffs Harbour area. We

are pleased to say that this meeting led to the organisation of Jagun Wellness Days.

The first Jagun Wellness Day was held on July 15, with 16 Elders attending. The topic was Self-management of Diabetes and the education session focused on: Carbohydrate metabolism and how carbohydrates impact on blood glucose levels Factors that affect blood glucose levels How to understand blood glucose results and dietary choices to avoid hypoglycaemia and hyperglycaemia The importance of nutrition for health and wellbeing The Elders also learned how to use a blood monitor and problem solve their blood glucose results.

LOOKING FOR SOME NEW WHEELS? Lismore’s Southside Health and Hire Centre (in association with Southside Pharmacy) have a large range of quality BARIATRIC and standard equipment for hire or purchase including shower chairs, lifters, electric beds, wheelchairs, seating, walkers, commodes and more.

Nurse Mary Lynch from Tweed Health for Everyone Superclinic and Dr Paul Davies at the fortnightly Fred’s Place clinic. The clinic operates in a purpose built room at Fred’s Place, a home and support service for people experiencing homelessness or those at risk of homelessness. Mary has worked at Fred’s Place since it began in late 2013. Paul began working there in September last year. He also works at headspace Tweed Heads and at Bugalwena General Practice at South Tweed, all run

by North Coast Primary Health Network. Patient numbers are steadily growing. During 2014/2015, Fred’s Place Clinic provided 119 GP consultations and 103 Community Nurse consults to 84 patients. Sixty-nine per cent of patients were male and 15% identified as Aboriginal and/or Torres Strait Islander. Thanks to Paul and Mary for their dedication and compassion.

Spring 2015 healthspeak

SOUTHSIDE HEALTH & HIRE CENTRE Call us today on (02) 6621 4440 or come in and say hello at 5 Casino Street, South Lismore.

Southside Health & Hire Centre Where your health is our total concern.

Nurse on Duty www.southsidehealthandhire.com.au

a publication of North Coast Primary Health Network

8:30am - 5pm Mon - Fri 8:30am - 12:00pm Sat Closed Sunday

11

The New, Improved Canning Tool

W

ith its track record of 10 years as a user-friendly, secure application for extracting and analysing primary health care data, The Canning Tool has recently undergone significant changes.

Since April, the Improvement Foundation has worked with Arche Health (Canning Tool developers) to update and improve the software. Consultation will continue with the user community to further develop the tool’s features, reports and measurement sets to meet primary health care needs.

In conjunction with the Improvement Foundation’s web portal, qiConnect, The Canning Tool provides a number of benefits that extend beyond data collection, by providing health services with the ability to: support quality improvement initiatives; benchmark data nationally and locally against peers; access resources that have been developed through a decade of quality improvement initiatives; and

network with colleagues through qiConnect.

Over 70 health services are using the new version and the initial results speak for themselves: “The installation of The Canning Tool was very simple and easy. The tool looks a lot simpler and cleaner and easier to use. The ability to connect into a file in Medical Director was also an advantage for ease of use. The print out is a lot simpler and easier to read than a previous extraction tool and the visual colour coding on screen makes it easier to distinguish outstanding actions/requirements.”- Practice Nurse - Roxby Downs Family Practice, SA. New Features

The Canning Tool now provides measures and reports in the following topics: diabetes, asthma, coronary heart disease, COPD, chronic kidney disease and chronic disease prevention.

Each report contains a patient list which enables you to view individual patient level data relating to the various measures which can be aggregated,

de-identified and uploaded to qiConnect.

Support

The Improvement Foundation is dedicated to supporting health services to access The Canning Tool. If you have any questions or would like someone to help you with installation, contact our support centre on 1800 173 868 Monday to Friday 8.30pm to 5.30pm (CST) or email data@ improve.org.au NCPHN offers support to general practice staff to access the Canning Tool. Please contact Deborah McPherson on 6627 3300, email dmcpherson@ ncphn.org.au; Kelli Babovic in the Tweed on 07 5523 5500, email kbabovic@ncphn.org. au; Anne-Maree Parry in the Northern Rivers on 6627 3300, email aparry@ncphn.org.au; Christine Cox in the Hastings Macleay area on 6583 3600, email ccox@ncphn.org.au; and Siobhan Breedon in Kempsey on 6562 1055, email sbreedon@ ncphn.org.au

Cultural Awareness Training

D

uring June and July, North Coast Primary Health Network offered Cultural Awareness Training events for clinicians in the Tweed and Mullumbimby run by the local organisation Banaam.

Banaam was founded by Fingal Heads community members Kyle and Josh Slabb who work with a team of mentors to actively get discussion going during the training sessions.

NCPHN’s Close the Gap Program Officer Susan ParkerPavlovic told HealthSpeak that the training focused on five key cultural principles – law, culture, language, ceremony and relationships.

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Josh Slabb from Banaam answering questions about culture and ceremony.

“The sessions centre on the importance for Aboriginal people of feeling connected to Country, and why relationships and cultural responsibilities are

so important to them.

Kyle and Josh also invite participants to ask any questions they wish about Aboriginal and Torres Strait Islander culture.

“This question and answer session is an effective tool to address perceptions and cross cultural conflict in a safe environment,” Susan said.

In Tweed 34 clinicians attended the Banaam training with 28 taking part in Mullumbimby.

Susan said NCPHN had received extremely favourable evaluations about the Cultural Awareness Training led by Banaam and the Network is looking forward to providing more in the future.

a publication of North Coast Primary Health Network

Educational videos online Healthy North Coast has a range of online videos on medical education topics available on its YouTube channel.

Here are some of the latest: Autism in Children – Dr Chris Ingall https://youtu.be/oHjmdoHl_hI Mindfulness expert Prof Paul Gilbert https://youtu.be/DJODN8gOzm4 Understanding Younger Onset Dementia – Dr Lana Kossoff http://healthynorthcoast. org.au/videos-7/ Substance Misuse in Later Life - Brian Draper https://youtu.be/zYtdoaGpEp4 Benzodiazepines - Dr David Heliwell https://youtu.be/hRKt8nWPxg4 Methamphetamines – A/ Prof Nicole Lee https://youtu.be/oR2EbcxJRGw Foetal Alcohol Spectrum Disorders – Prof Elizabeth Elliot https://youtu.be/srtpO6gQGC8 Medicinal Cannabis and GPs – Dr Alex Wodak https://youtu.be/sKjFOSD4S-8 Opioid Treatment Program - Ray Boegart https://youtu.be/wcS_ PmJs91k Post Natal Depression – Dr Rosalind Foy https://youtu.be/R_ bB3umxRsg Protecting Children from Second Hand Smoke – Laura Jones https://youtu.be/dpTGxE4zwm4

healthspeak Spring 2015

Plan spells out Aboriginal health priorities

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orth Coast Aboriginal Elders, Aboriginal health and community organisations, North Coast Primary Health Network, FACS, TAFE and Northern NSW Police came together with Northern NSW Local Health District early in August to launch the Northern NSW Integrated Aboriginal Health and Wellbeing Plan for 2015 to 2020.

More than 12 months in development, the Plan has been pulled together after 35 consultation sessions held across Northern NSW to discuss key Indigenous health and wellbeing issues in Aboriginal communities.

At the launch NNSWLHD CEO Chris Crawford said that some of the concerns raised during consultations included substance abuse, sexual health and communicable disease, maternal and child health, chronic disease and the shorter life expectancy

Steve Blunden, General Manager Casino AMS; Mick Roberts, Bundjalung Elder; Heather McGregor, North Coast TAFE; Inspector Nicole Bruce; Aunty Muriel Burns, Yaegl Elder; NNSWLHD CEO Chris Crawford; Deb Monaghan, NNSWLHD Board member; Mark Moore, Bullinah AMS General Manager; Kym Langill, FACS; Scott Monaghan, CEO Bulgarr Ngaru; NCPHN CEO Vahid Saberi; Sue Follent, Executive Officer Ngayundi Aboriginal Health Council; Maureen Lane, Manager Planning & Performance NNSWLHD.

of Aboriginal people.

“While close attention was paid to these concerns, the poorer health status of the Ab-

original community is not just about health,” he said.

“It is also about the provision of housing, drinking water,

and sewage services for local residents.”

The five year plan sets out priorities and actions for the Health District and other agencies to deliver improved health and wellbeing services in partnership with Aboriginal people.

“The Plan recognises the differing needs of Aboriginal communities across Northern NSW, and provides for more effective engagement between government and non-government agencies, and the broader Aboriginal community, to provide a more integrated approach to planning, funding, and delivering health services to Aboriginal people,” Mr Crawford said.

The Plan comprises three volumes and includes a detailed profile of Aboriginal health and wellbeing in Northern Rivers Aboriginal communities - the Bundjalung, Yaegl, Gumbaynggirr, and Githabul Nations.

Bowraville Healthy Liver Event

A

Hepatitis and Healthy Liver event for the community was held at Bowraville Hall in the Nambucca Valley on July 29 to mark Hepatitis Awareness Week.

The event was jointly organised by North Coast Primary Health Network’s Aboriginal Health team and the Mid North Coast Local Health District Coffs Harbour Viral Hepatitis clinic.

Information was available on how to keep your liver healthy and free of hepatitis and clinicians were on hand to answer questions about hepatitis treatment and care. The day also included a popular art workshop and competition to design a health promotion logo.

This event was made possible

Spring 2015 healthspeak

Bowraville community members of all ages learnt about keeping their livers healthy during Hepatitis Awareness Week.

through a Hepatitis Week grant from Hepatitis NSW, a charity that works to prevent the transmission of viral hepatitis and to improve the health and

well-being of affected people and communities.

Hepatitis B and C can cause serious liver disease if left untreated, including liver cancer,

a publication of North Coast Primary Health Network

liver cirrhosis and liver failure.

Together, these viruses claim more than 1,000 Australian lives each year.

People living with hepatitis B or C may have very few symptoms (or none at all), until the liver becomes severely damaged.

That’s why it’s essential that Nambucca Valley community members understand who may be at risk of hepatitis B and C take action and get tested, and if found positive, speak to their doctor about regular liver check-ups and treatment. There is a safe and effective vaccination for hepatitis B. While there is not a cure for those living with chronic hepatitis B, ongoing monitoring and treatment can help protect against further liver disease and liver cancer.

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What is audiometry?

What is?

A

udiometry is the measurement of the range and sensitivity of a person’s sense of hearing. It is used to diagnose hearing loss and/or middle ear dysfunction. The test focuses on the frequency and intensity of speech. Typically air conduction, bone conduction, speech discrimination and tympanometry tests are performed. This battery of tests can determine and type and severity of the hearing loss and which part of the hearing pathway is affected.

These tests are performed using specialist equipment and software as well as a Tympanometer machine for diagnosis

of middle ear pathology. The results are shown on an audiogram and a read out from the Tympanometer.

There are three types of hearing loss – sensorineural, conduc-

Kate Francis, Audiometrist

Profile

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udiometry is Kate’s second career. She became disillusioned with her first choice of Social Science after working in the field for a few years and when she re-entered the workforce, she secured an admin position at a hearing clinic. Fortunately the clinic’s management recognised Kate’s empathy and determination to succeed and offered to fund her audiometry training and to supervise her.

I am very grateful to have been given the opportunity as now very few organisations offer this kind of support,” she said.

Working full-time and studying took much dedication but Kate has now been fully qualified for over two years and continues to enjoy her work.

She’s worked for two hearing providers in Coffs Harbour and has a diverse range of clients which present different challenges.

“Audiometry is very rewarding as you see results quickly.

If a client needs a hearing

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tive and mixed (a combination of sensorineural and conductive).

Sensorineural hearing loss occurs when there is damage to the inner ear (cochlea), or to the

nerve pathways from the inner ear to the brain. Usually, this hearing loss cannot be medically or surgically corrected and the individual will be fitted with hearing devices. This is the most common type of permanent hearing loss.

Conductive hearing loss comes from issues in the middle ear and can often be medically or surgically corrected. This type of loss is referred to a GP and/or an ENT. Mixed hearing loss may need both medical and/or surgical and a device fitting.

Bilateral hearing loss is more common than unilateral.

I’d saved their marriage as she was ready to leave her hard of hearing husband out of pure frustration device they are usually fitted with hearing aids a week after the hearing test. The initial appointment is the most challenging for the client and their family.”

Kate explained that if the client hasn’t acknowledged they are having problems understanding speech they are often defensive and not happy to be at the appointment.

“This is where my training in counselling and an empathetic, caring manner come in to play.

It’s the part of the role I enjoy most. I listen without judgment, I empathise with the client and family, then help them find the best solution.

“Very early on in my career, a client’s wife approached me in the street and told me that in all seriousness I’d saved their marriage as she was ready to leave her hard of hearing husband out of pure frustration,” Kate told HealthSpeak.

Kate said that hearing loss is an unseen disability and often one that people are reluctant to get help for.

“People feel that hearing aids are telling the world that they are old and that there’s something wrong with them. This is the biggest hurdle I face with each new client. Women are far more likely to seek help and be

a publication of North Coast Primary Health Network

happy about wearing aids, we love to talk! While men rarely want hearing aids, especially the older, more traditional man.

Kate doesn’t hesitate in recommending audiometry as a career.

“It is very satisfying to have a client go from being almost reclusive and not being able to understand conversations around them, to being a happy, confident person who tells you how great it is to hear their grandchildren or have whispered conversations with their friends.

“I hope over time people will change their view about hearing aids being ‘something old people need’ to understanding that such aids are something that will allow them to have a more fulfilled and enjoyable life.”

Kate is happy to visit general practices in the Coffs Harbour area to give a one-hour presentation on Hearing Health that earns GPs two RACGP CPD points. Contact her on 6651 6866.

healthspeak Spring 2015

Breaking down barriers F

or the past couple of months, Christopher Keuntje, North Coast Primary Health Network’s Aboriginal Outreach Worker for the Tweed, has been building bridges at mainstream general practices in the area.

Christopher had been working for Goulburn Valley Medicare Local in Shepparton, Victoria before joining NCPHN and he brought a novel idea with him that he’d implemented down south.

For a couple of days each week, he’s been sitting in the waiting rooms of general practices that have a substantial number of Aboriginal patients and making himself available to Indigenous and non-Indigenous patients and the practice staff.

He greets patients as they come in the door and starts up a conversation. Chris is also spending one day a week at headspace Tweed Heads and sitting in at Bugalwena General Practice at South Tweed.

Christopher, who has an extensive nursing background, told HealthSpeak that sitting in these medical centre waiting rooms had proved beneficial in many ways.

“I approached the practice managers at Banora Point Medical Centre and Tweed City Family Practice and suggested that through setting up a table with resources in their waiting room I could provide health education and information to both clinical staff and the patients.. It’s a way of breaking down medical jargon and it’s also helpful for non-Indigenous people to see me interact with my own people.

It gives them the confidence to strike up a conversation with an Aboriginal person. Some of them tell me they’ve never met an Aboriginal person before.

I tell them there are plenty of us out there (laughing). And they are surprised when I tell them about the difference in Spring 2015 healthspeak

Banora Point Medical Centre Practice Manager Kym Ottery, Christopher Keuntje and Katie Marrison.

life expectancy and about other Aboriginal health issues,” he explained.

Chris said that a lot of Aboriginal people choose not to access an Aboriginal Medical Service and the work he does within mainstream practices enables staff to adopt more culturally appropriate practices “Often the non-Indigenous staff want to know how to approach an Aboriginal person.

They’re concerned they’ll say the wrong thing and offend someone. I tell them that you talk to them like anyone else, ask a few questions about family and where they are from and you’ll start to build a connection with them.”

Once Chris approached the clinics and got the go ahead, he also wrote an introductory letter that was sent out with invitations for Aboriginal patients to attend a health check.

“So then people were aware that I was there and the Aboriginal clients came in and found out what services I was providing, it’s been really positive,” he said.

In conjunction with practice managers, Chris has organised half days dedicated to health

Often the nonIndigenous staff want to know how to approach an Aboriginal person.

They’re concerned they’ll say the wrong thing checks for Aboriginal patients where he’s available to sit in on the consultation with patients if they wish. His nursing experience allows him to speak to patients in easy to understand language about their health issues during the examination.

And afterwards, Christopher is able to refer patients to his colleagues at North Coast Primary Health Network.

“A couple of weeks ago I did a health check day at Tweed City Family practice. We had five people booked in, four of them I identified as having chronic diseases, so we referred these patients to my colleague Leisa Lavelle who runs the Care Coordination and Supplemen-

a publication of North Coast Primary Health Network

tary Services (CCSS) program and to Susan Parker Pavlovic, NCPHN’s Closing the Gap Program Officer.”

Making these referrals has enabled those patients to access medical aids under the CCSS program and to get help with travel through Tweed Byron Community Transport to attend specialists’ appointments.

There’s no doubt that Christopher’s warm, engaging personality has a lot to do with his success in breaking down barriers. His enthusiasm and his enjoyment in meeting people are clear.

Christopher’s family life probably also helped sharpen his communication skills. As the second oldest child, he had to step up and take responsibility for his younger siblings when his parents both died when he was just 19. The son of a German father and an Aboriginal mother, Chris was raised in the European way. Four siblings resemble his mother, while one sister is blonde, blue eyed and fair skinned.

Chris left school at 14 to work on his parents’ fruit farm at Shepparton and when he found himself alone and needing to hold the family together he decided he needed to get an education.

“I had four younger siblings to raise, including a six-month old baby, so I had to get myself an education. I educated myself of a night time while my sister who was a bit down from me looked after the others.

“I don’t regret any of it. I didn’t want my siblings to go into care because that was something that Mum used to stress to us all the time. I went back a couple of years ago to South Australia and found out about my mother’s family and my culture. So I’m a Ngarrindjeri boy from Raukkan (Point McLeay Mission) near Murray Bridge, the mission where my mother

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From previous page

was born. The old gentleman on the fifty dollar note is my great uncle,” he said proudly.

Chris intends to work in mainstream practices for around three to four months at a time.

After that staff will be in a much better position to work with Aboriginal patients and be aware of available services and general practice incentives. He’s already lined up to go and sit in at Mullumbimby Medical Centre in a while.

Apart from the liaison work, Christopher has also helped practice staff with administration.

“I’ve been cleaning up files and data,, talking to them about identifying Aboriginal patients, talking about follow ups, the health checks and the incentives for the medical centre to looking

after Aboriginal patients. And it’s all helping to break down barriers for our people to access mainstream services,” he said with a broad smile.

Kim Ottery, Practice Manager at Banora Point Medical Centre, told HealthSpeak that Christopher had been a massive help in bringing staff up to speed about Indigenous health issues and their entitlements under the Closing the Gap Program.

“He’s also provided our GPs with educational sessions during their lunch breaks and has been very ‘hands on, helping us to better care for our Indigenous patients,” said Kim. With Christopher’s support, Banora Point Medical Centre also held a stall during NAIDOC week and commenced ATSI Health Check mornings.

gp secured for Coraki

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orth Coast Primary Health Network (NCPHN) is delighted to announce that the Maria Clinic in Casino will be opening a general practice at Coraki in September.

NCPHN’s General Manager, North, Mr Chris Clark, said the opening of the practice was an exciting development.

“It’s very pleasing to have come to this agreement with the Maria Clinic to provide the community of Coraki and surrounding areas with medical support. The Coraki practice will start off part-time, building up to full-time as the

practice grows,” he said.

Mr Clark thanked the people of Coraki and the Northern NSW Local Health District for their support in the process of securing a new GP for the town.

The new service in Coraki was the culmination of a tender process inviting local general practices to operate a practice in the town. The tender winner, Maria Clinic, is a well-established medical clinic in Casino offering a wide range of medical services.

View past issues Did you know you can read HealthSpeak online?

Go to www.issuu.com/healthspeak and see all 13 issues.

Supporting the expanding role of practice nurses

By Professor Iain Graham Dean, School of Health and Human Sciences Southern Cross University

“I look to the day when there are no nurses to the sick but only nurses to the well.”

Florence Nightingale, address given to the Chicago Exhibition, 1893

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n July the School of Health and Human Sciences at SCU hosted an evening with a group of practice nurses at the behest of the North Coast Primary Health Network to discuss their role in providing more integrated care in the primary care setting.

Following the evening, it is intended to provide education, a forum for debate and a strategic vision to guide future development so that patients can have greater access to health services, capacity is built among the practice nurse workforce and quality, safe care is provided. Care that is aimed, as Nightingale alluded,

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to keeping people healthy and well maintained if afflicted with chronic health problems.

General practice is the cornerstone of primary health care. Ongoing care for people with chronic health or disabilities is going to be in increasing demand, particularly given the ageing population. Increasingly, this care will be provided within interdisciplinary health and social care teams. Appreciating the changing role of family members needs to be acknowledged too!

Currently both registered and enrolled nurses are employed in general practice, often working in professional isolation. Such isolation has contributed to these nurses feeling bereft of information and educational opportunities. These nurses have worked closely with GPs, but the future requires them to work with other health care professionals.

These nurses have a range of skills and knowledge used in a variety of settings. These include health assessment,

health care planning and evaluation as well as health interventions. However, the breadth of patient presentations is requiring nurses to extend their scope of practice.

The North Coast Primary Health Network believes that working with the School will help this group of nurses expand their role by providing accredited and non- accredited education offerings. We also need to put in place a mentorship program and clinical supervision network to ensure reflective practice and professional appraisal. This could be linked to portfolio-based learning.

a publication of North Coast Primary Health Network

Over the past 18 months the university has been working with an educational technology company to better shape the student learning experience. The School is working with the company to design its ‘Master in Health Leadership’ whereby, ‘SCU on-Line’ comes to life. What is particularly significant is the flexibility of this type of education which can be learning is being tailored much more to an individual’s needs.

Registered and enrolled nurses working within general practice must meet the Australian Nursing and Midwifery Council’s national competency standards. In addition, they should also meet the competency standards for nurses in general practice. It is anticipated that the evolving relationship between the School and the Primary Care Network will enable this process to gain speed and move forward - finally achieving what the Florence Nightingale address stated in Chicago in 1893!

healthspeak Spring 2015

Understanding Trauma Informed Care

By Mim Weber Mental Health Program Coordinator, NNSW LHD

T

here is a very strong link between people’s experience of childhood trauma and problematic physical and mental health outcomes. It is important to know how best to respond to people with trauma histories so as not to exacerbate the effects of the trauma.

Prevalence of trauma is high.

Seventy-six per cent of adults reporting child physical abuse and neglect experience at least one psychiatric disorder in their lifetime, 50% three or more disorders.

Fifty per cent of people with schizophrenia-spectrum disorder have experienced some form of child abuse. The more severe and prolonged the trauma, the more severe the psychological and physical health consequences.

The ACE study found significant links between the number of adverse (traumatic) childhood experiences and mental health issues including attempted suicide, depression, anxiety, being prescribed anti-psychotics or mood stabilisers, voice hearing, sleep and memory problems, substance misuse. Also physical health issues including sexually transmitted disease, severe obesity, ischemic heart disease, cancer, chronic lung disease, skeletal fractures and liver disease.

Brain studies have identified the effects of trauma on the brain. The neurochemical and physical changes in the brain can have biological as well as psychological and behavioural effects on a person’s health. Some of these include: difficulties using language to describe or talk about the trauma; difficulties with attention, learning or memory; difficulty establishing context when experiencing fear; heightened emotions; sensitivity to cues for threat; difficulty interpreting and regulating emoSpring 2015 healthspeak

Further resources Ted Talk by a paediatrician: http://www.ted.com/talks/nadine_burke_harris_how_childhood_trauma_affects_health_ across_a_lifetime It’s Just good medicine: Trauma informed primary care 2013 http://www.integration.samhsa.gov/about-us/CIHS_TIC_Webinar_PDF.pdf Trauma Informed Practice Guide 2013: http://bccewh.bc.ca/ wp-content/uploads/2012/05/2013_TIP-Guide.pdf

tion; less reward and pleasure anticipated from activity; greater attention to nonverbal ‘negative’ information.

There may be triggers which elicit powerful memories associated with the trauma, or flashbacks in which the person experiences the past as if it was in the present.

What has this to do with Primary Health Care?

Many trauma survivors do not seek mental health services, but look for help in primary care settings, presenting with physical symptoms. Many feel vulnerable when accessing health services which might be unintentionally exacerbated by health service practices. This may trigger memories or responses to perceived threats which are re-traumatising.

Problem behaviours may actually be coping strategies people use to deal with overwhelming emotions or memories.

Trauma informed care recognises the prevalence of trauma in people’s lives, understands the

effects, and works to minimise the chance of re-traumatising or triggering people, instead enhancing opportunities for healing.

The trauma-informed ‘principles of sensitive practice’ are: Respect - taking time so patients feel genuinely heard and valued; Rapport - developing a tone that is professional yet caring, expresses empathy and helps patients feel safe; Sharing information - offering explanations and providing

briefs

Video cats improve mood Watching cat videos on the internet could be a low-cost intervention improving emotional wellbeing, a researcher says.

US media researcher Jessica Gall Myrick conducted an on-line survey of 6000 people, finding cat-related media content improves mood. She says scientific studies of pet therapy have shown time

a publication of North Coast Primary Health Network

the rationale for questions asked; Sharing control - eg include the patient in treatment choices; Respecting boundaries - eg asking permission before beginning a procedure; Fostering mutual learning - encouraging patients to become active in their own health care; Understanding non-linear healing – recovery from trauma is not a linear process; Demonstrating awareness and knowledge of interpersonal violence – eg having pamphlets and information in the waiting room and in the room with the patient.

In addition, the practitioner should: be mindful of possible stress reactions and address these in a respectful fashion; knowing how to respond appropriately if the patient is triggered or dissociates – grounding techniques; understanding that knowing about the effects of childhood trauma could be crucial in accurately diagnosing and treating somatic and psychosomatic complaints; knowing when and how to ask about trauma history – if the patient has numerous painful chronic health symptoms, or psychiatric symptoms such as PTSD, panic attacks, depression or dissociation, the patient has a hard time establishing trust and has feelings of helplessness, shame or guilt, or the patient has extreme difficulty with medical procedures.

spent with real animals improves mood and wellbeing so virtual experiences might be useful and much cheaper.

As of 2014 there were more than 2 million cat videos on YouTube and research shows internet users are more likely to post cat images than selfies.

The study found viewing online cats led to respondents experiencing a significant increase in hope, happiness and contentment, as well as reduced negative emotions such as anxiety, sadness and guilt.

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And then I had breast cancer A

French-born woman living in Port Macquarie with her partner and four year old son has produced a cartoon booklet outlining her journey with breast cancer.

In 2012, Magalie Lameloise felt a lump in her breast but never thought it could be cancerous.

“I was feeling good and healthy, I was 33 years old, no way it could be serious…,” she thought.

Magalie went to her GP to have the lump looked at and her doctor thought it was probably not serious either because of her age, but sent her to have an ultrasound and a mammogram.

“The results were inconclusive, so I was sent for a biopsy,” Magalie explained. “Only a week later, I was diagnosed with breast cancer.”

Despite Magalie’s lump being small and caught early, it was quite an aggressive type of cancer, so she had 10 months of treatment including surgery, chemotherapy and radiotherapy all done at the Royal Women’s Hospital in Randwick.

“When I was diagnosed with breast cancer, my partner and I went searching for something to read, but it was hard to find something that was not full of medical lingo. My partner gave me this idea that I should start drawing my story and posting the images on a blog. He even got me the graphic tablet for my birthday. (See Magalie’s blog at http:// magsblog.com) “I always enjoyed reading comic books so I really liked the idea and I started drawing.

I wanted to share my story a bit differently - in a simple way and with a bit of humour.

Magalie Lameloise with her booklet

At first, it was taking me a very long time because I have never drawn before!” said Magalie.

Her drawing kept Magalie’s mind busy during her treatment and really helped her to get through this journey. I was more focusing on ‘what can I draw next?’ instead of ‘why this is happening to me?’”

The blog rapidly became a success in Australia and in France and she received lots of supportive and friendly messages from people all over the world. The decision to produce the booklet came from messages from young women with breast cancer saying they wished they’d been able to read Magalie’s cartoons at the start of their cancer journey.

“This is why I decided to print my cartoons into a booklet to be given for free to younger

women who have just been diagnosed with breast cancer,” she told HealthSpeak.

Magalie launched a crown funding campaign on the internet which was a success and was able to print 1000 copies in English and 1000 in French. Already 600 booklets in English have be sent to hospitals around Australia and overseas. Magalie said she’d received very nice feedback from breast care nurses all around Australia.

“They are saying that my booklets are a great source of information for every woman facing breast cancer, but also for the people who care about them. They are accessible to everyone. They provide information in a simple way and with a little bit of humour.

My booklet is saying ‘you are not alone, I had cancer too’”.

The Breast Cancer Network Australia has helped Magalie distribute 400 copies and she has now done a second print run 0f 1000 to distribute in the Hastings/Macleay area. The Hastings Cancer Trust is supporting her project. Magalie has 400 copies of her booklet left and would be happy to send copies to anyone who could use them.

“I am hoping that my booklets will reduce the stigma about breast cancer and raise awareness in our community - not only to young women with breast cancer, but to everyone who has a woman in their life.”

Magalie finished her cancer treatment two years ago and is feeling well and enjoying life with her family in beautiful Port Macquarie.

She became an Australian citizen last year.

Contact Magalie at: magsblog@yahoo. com) or on 0406 430 384.

New MNC staff sexual health specialist

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he Mid North Coast Local Health District has a new staff specialist, focusing on HIV and sexual health. Dr Emanuel Vlahakis will be providing specialist services from Port Macquarie to Grafton on a regular basis.

Dr Vlahakis brings extensive experience from clinical international postings, research collaborations and from his years working at the Taylor Square Clinic in

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Sydney, which is one of the largest private HIV/ Sexual Health practices in NSW. Over the coming months, Dr Vlahakis will be expanding access to clinical services across the Mid North Coast to meet the needs of the community. He is keen to encourage people to regularly access services for screening and treatment for sexually transmitted infections and for those who require specialist

HIV clinical management to make contact.

To access services visit: http://mnclhd.health.nsw. gov.au/services/hiv-andrelated-programs-harp/ sexual-health/ For clinic appointments or information please call: Coffs Harbour 6656 7865, Grafton 6641 8712, Port Macquarie and Kempsey 6588 2750.

a publication of North Coast Primary Health Network

Dr Emanuel Vlahakis

healthspeak Spring 2015

What is Exercise Physiology?

What is?

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ccredited Exercise Physiologists (AEPs) are allied health professionals, providing exercise and lifestyle therapies for the prevention and management of chronic disease, injury and disability.

AEPs work in: private clinics hospitals occupational rehabilitatio n companies employment agencies gymnasiums GP super clinics research institutes An AEP can help overcome persisting pain caused by injury or overuse improve your heart health

Profile

rehabilitate following a cardiac event control diabetes prevent pre-diabetes from progressing to full diabetes improve recovery following cancer treatment improve general health and wellbeing AEPs also provide training in safe manual handling;

Spring 2015 healthspeak

Information from the Exercise and Sport Science Australia website at: www.essa.org.au

Michael Woods, Exercise Physiologist

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ichael has been involved in clinical practice for the past 30 years.

Before this he completed the Sports Science course at Northern Rivers College of Advanced Education. At the time he’d also been heavily involved in coaching both athletics and Rugby League.

“From there I had the great fortune of being involved in a sports medicine clinic. It was a very collaborative and supportive environment. I was blessed to have had the support and mentorship of a physiotherapist, doctor and orthopaedic,” he said.

For the last 25 years Michael has been working in his own clinic in Lismore and for 13 years he has also been consulting in multidisciplinary physiotherapy clinics at Robina and Brisbane’s West End during the week. He’s clearly a man in demand.

“For the last 18 months I

perform functional assessments; carry out sub-maximal and maximal fitness tests; perform body composition tests and musculoskeletal assessments and provide lifestyle education to help people manage health conditions.

AEPs hold a four-year university degree provide support for clients with conditions such as cardiovascular disease, diabetes,

osteoporosis, mental health problems, cancer, arthritis, pulmonary disease and more.

They are eligible to register with Medicare Australia, the Department of Veterans’ Affairs and WorkCover and are recognised by most private health insurers.

Accredited Exercise Physiologists are not Personal Trainers.

They are allied-health professionals with Medicare Provider numbers and are trained members of the health and medical sector. Fitness professionals (eg personal trainers) are members of the sport and recreation sector.

have been consulting with the National Athletics jumps team, based at the QAS in Brisbane, for prehab and rehab leading up to the World Championships ‘15 in Japan and next year’s Rio Olympics,” Michael told HealthSpeak.

Michael sees exercise physiology playing an expanding role in health care.

“As the name suggests, exercise prescription forms the main component of our approach.

Predominately, I work with referred chronic pain condi-

tions. Although the majority are musculoskeletal, we have had the benefit of also working with a number of neuromuscular conditions. With the expanded Medicare format involving EPC or Chronic Disease Management, exercise physiology has an expanded role with all these related conditions.

“Exercise has always been a complimentary medicine. The prescribed exercise has to be relevant for the condition but also for the patient. So often people are told they need to exercise, but aren’t told what type is most relevant for them, or they are unable to exercise due to pain. The role of the exercise physiologist is to make the exercise relevant to both the condition and the client.”

Michael has found his career very rewarding.

“The expanding role of the exercise physiologist, the variety of the client base and

a publication of North Coast Primary Health Network

the increasingly collaborative nature of the work ensures that both the enjoyment and the challenges remain.”

Michael considers it a great privilege to work with patients.

“Despite the often negative processes and the chronic pain, their perseverance, their resilience is both humbling and inspiring,” he said.

Michael would recommend exercise physiology as a career for its scope and its broadening role in health care.

“I have the great privilege of working with my daughter who is also an AEP, finishing her Masters in Exercise Science. Exercise can play such a large role in the quality of our lives, impacting both prevention of and recovery from illness and disease. Importantly, exercise can give us control over our lives. How we respond to it as an integral part of health care is the challenge for the future,” he added.

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Koori Grapevine Family Day at Casino

Planting the Seed in Coffs

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From left: Liz Lewis, NNSWLHD Aboriginal Immunisation Support Officer; Kresta McQueen, Dental Therapist; Kali McWilliam, Speech Pathologist and Joan Clay, New Directions Nurse. The students in the white shirts are from Griffith University’s Hope4Health program.

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he Northern NSW Local Health District’s staff promoting immunisation at the Casino NAIDOC Family Fun Day told HealthSpeak they were pleased to find themselves set up adjacent to the North Coast Primary Health Network’s team at Crawford Park. NCPHN staff were holding cooking classes showcasing Quick Good Tukka and attracting a lot of interest from youngsters.

NNSWLHD’s Aboriginal Immunisation Support Officer Liz Lewis said that she was able to encourage youngsters turning up for cooking class to come over to her stall to do some painting. Liz told HealthSpeak it was a rewarding day with both organisations working in partnership to deliver healthy messages.

“It was great to be set up next to Jamie Wimbus and Claire Malseed who were busy cooking omelettes as I was able to encourage the kids involved in the cooking to take part in hand painting afterwards.

“They enjoyed creating artworks promoting the theme: ‘Be Wise, Immunise’ and ‘Be Deadly, Let’s get our Jarjums Immu20

nised’,” Liz said.

The staff from Casino AMS also played a major role at the Fun Day, provide healthy teeth and wellbeing checks to community members.

The Family Fun Day on July 6 was organised by North Coast Public Health Unit in conjunction with Casino Aboriginal Medical Service. The community and service providers came together to celebrate the NAIDOC theme ‘We all Stand on Sacred Ground’.

Thanks to the Aboriginal community of Casino for a great day of learning from each other.

NAIDOC in the Northern Rivers

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orth Coast Primary Health Network staff came up with some innovative ideas following a customer survey on what the Aboriginal community would like to see at NAIDOC Week events.

During July, NCPHN’s Closing the Gap Team in the

ore than 200 people attended a NAIDOC Week event at Diggers Beach Reserve hosted by North Coast Primary Health Network’s Closing the Gap staff, Coffs Harbour Aboriginal Social Events Committee and the Coffs Harbour and District Local Aboriginal Land Council.

Planting the Seed, Caring for Country was the name of the event connected to this year’s NAIDOC theme - “We all stand on sacred ground, learn, respect and celebrate.”

To literally plant the seed, the Darrunda Wajaarr Green Team from Coffs Harbour Land Council planted around 60 native species that they’d propagated. They’ve been doing this for some years now and the change in the beauty of the landscape at the reserve is remarkable. Thanks to National Parks and Wildlife Service for preparing the ground and helping children and Elders put the seedlings in the ground.

NCPHN’s Closing the Gap Team ran a health quiz which attracted 93 entrants, all keen to learn more about good health and perhaps snag a prize. Uncle Mark Flanders

Northern Rivers held stalls at NAIDOC events in Casino, Lismore, Kyogle, Wardell, the University Centre for Rural Health, Coraki, and at the Southern Cross University campus in Lismore. Based on community feedback, staff gave healthy cooking demonstrations, helped youngsters make delicious omelettes, gave a hands on demonstration on the amount of sugar in popular

a publication of North Coast Primary Health Network

From left: Reuben Robinson, DAA; NCPHN’s Helen Lambert and Terry Donovan cutting the cake at the Plant the Seed event.

conducted a bush tucker tour and there was music from Gumbaynggirr musician Matty Devitt and Big T. Jeremy Devitt and his deadly group of young dancers Wajaarr Ngaarlu entertained the crowd.

There was also a clay art workshop run by Uncle Tony Hart. Participants enjoyed making models of animals and also painted them. Kids also enjoyed face painting, a circus playground and a jumping castle. A healthy barbecue lunch was provided by the Mid North Coast Local Health District.

drinks and provided fruit for the community, showing how to make ‘apple slinkys’.

Merchandise included NAIDOC stress balls, drink bottles, writing kits, wristbands and footballs. Raffles were also held to win NAIDOC shirts, bags and large first aid kits. The Kyogle NAIDOC March and activities were combined with Reconciliation Week festivities.

healthspeak Spring 2015

Cancer Care Yarn Up Day

Aboriginal health traineeships on MNC

NNSWLHD’s Teena Binge with Uncle Micky Ryan

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embers of the Lismore Aboriginal community took advantage of a special event at Jullums - Lismore Aboriginal Medical Service in early June.

The Cancer Care Yarn Up Day was organised by NNSWLHD partnering with Lismore Aboriginal Medical Service.

In the front yard of Jullums a range of local organisations were available to discuss their services and promote activities. These included the Family Referral Service, Quit for Life, Core of Life and Sustaining NSW Families.

Next door at the University Centre for Rural Health lecture theatre an impressive line up of health professionals presented short talks on topics of interest including breast cancer screening and care, prostate cancer, bowel cancer, pap smears, cervical cancer and skin cancer.

The audience were attentive and had many questions about the various topics presented.

Uncle Micky Ryan performed the Welcome to Country and a barbecue lunch was hosted by Rekindling the Spirit.

Jubullum Family Fun Day

The Jubullum Family Fun Day at Tabulam on June 30 was organised by Richmond Valley’s Bulgarr Ngaru Aboriginal Medical Corporation for community members of all ages.

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he Family Fun Day included showcasing a range of services with participation from Bulgarr Ngaru , North Spring 2015 healthspeak

Coast Primary Health Network Aboriginal Health team, headspace, NNSW LHD Health Promotion and Solid Mob.

MNCLHD Governing Board Chair Warren Grimshaw AM with Liam Donovan, a school-based trainee working with the Health District’s IT division at Coffs Harbour Health Campus.

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n June, the Mid North Coast Local Health District (MNCLHD) launched a school-based Aboriginal Traineeship program at the Nambucca Entertainment Centre.

The Elsa Dixon Aboriginal Employment Program has helped fund a pilot schoolbased traineeship program for the MNCLHD to promote workforce diversity and innovation for the Health District and better health outcomes for patients.

Twenty-five Aboriginal trainees have begun their two-year traineeship with the Health District, working in nursing, allied health, IT and admin across all health sites.

NCPHN’s Closing the Gap team helped youngsters cook some healthy omelettes in their Quick Good Tukka healthy cooking classes and adjacent to their stall, NNSWLHD’s Aboriginal Immunisation Officer Liz Lewis was supervising kids to include their hands in a painting promoting Immunisation. The artwork will be going up on the wall of the Jubullum pre-school for the community

a publication of North Coast Primary Health Network

On completion of their traineeships, the students will have achieved a nationally recognised qualification in their chosen field, which contributes to their Higher School Certificate.

Two Student Support Workers provide extra assistance to the trainees and they will work closely with local secondary schools, the Aboriginal community, State Training Services Office and MNCLHD. The MNCLHD Aboriginal workforce stands at 3.4 per cent, which is above the NSW Health benchmark of 2.6 per cent, however Mr Dowrick would like this figure to increase to five per cent.

to admire.

Around 80 community members came along with other attractions including a mechanical bucking bull, a circus performance, songs by Tom Avery aka Blakboi and a hip hop workshop by Mitchell King.

There was also a tasty barbecue which included kangaroo steak and salad prepared by Bulgarr Ngaru clinic staff.

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Arts Health & Wellbeing

The transformative power of the pen I t takes just one event to completely alter the course of a person’s life.

Lennox Head GP Hilton Koppe knows this only too well.

Twelve years ago he had an interaction with a patient that opened up his life in a way he wouldn’t have dreamt possible.

It all began with a poem penned by the patient who had been suffering from depression.

Hilton said the patient asked if he would like to read some of her poems and he took them home. Late one night when the rest of the house was asleep, Hilton went through the poems and came across one entitled ‘And You’.

“This was a patient whom I thought I’d really helped and her poem ended with the words “Perhaps I should instead seek a vet.”

Hilton said he was gutted, and with no one to talk to a glass of red wine was looking attractive.

“There was a glass of red wine and a pen and I decided there wasn’t enough wine in the world to make me feel better, so I thought if she could write a poem about me, then maybe I could write a poem about her.”

Hilton hadn’t written anything creative since high school and says he’s enormously grateful to his patient as her poem changed his life completely.

He is now practising as a GP and holding creative writing workshops internationally.

Hilton is also in demand as a speaker on the topic of the therapeutic value of creative pursuits.

And in August he presented a pre-festival workshop for the general public at the Byron Bay Writer’s Festival.

Initially Hilton started running creative writing workshops for GPs, to help them process 22

Hilton Koppe

some of the emotions they encounter during the long term relationships they forge caring for patients. He found the writing also enabled them to communicate more effectively with patients in a heartfelt way.

“As a GP you meet a patient when they are young and healthy and then they get married and have kids and then you might have to tell that person they have breast cancer. The GP takes them through treatment, then remission and relapse, palliative care and death. And then the GP is responsible for the after death care of the rest of the family, without a lot of training,” he explained.

His work then expanded to include other health professionals and children undergoing treatment for cancer.

Most recently Hilton’s taught two very different groups of people in the US – war veterans with severe PTSD and a group of young mental health inpatients. It’s the fifth time Hilton has been invited to work in America through Harvard and the University of Iowa and on this occasion he was also invited

That guy had been coming to the group every day for two years and had hardly spoken, and today he’d stood up and read aloud.

by Harvard Medical School to do some teaching with their students, patients and staff. They even gave him the fancy title of ‘Visiting Professor of Humanities and Medicine’.

“In Boston the veterans were aged between 30 and 70, seriously and chronically mentally ill and I was very nervous about their ability to engage with the process. All I knew is that they would have been long term institutionalised but now live in the community and that they come to this centre every day and have done for many years,” said Hilton.

“I thought if I can just meet

a publication of North Coast Primary Health Network

them human to human it will be okay. So when I arrived at this old hospital, I told them my story. I said I come from Australia, Lennox Head, a small town of about 2000 people. I showed some photos including one of my patients in my own practice. I described a bit what my practice is like. I told them that some of my patients are police who have post traumatic stress disorder so I had a little idea about the things they might be experiencing. Then I just stopped and said ‘Has anyone got any questions?’”

Hilton spent the next 20 minutes answering questions about life in Australia, football, kangaroos, where he got his shoes, how much did his shirt cost, about his practice and how come he was doing this work?

He then presented some writing exercises based on the mind – ‘what colour would your mind be, what food what your mind be, what animal would your mind be?’ in order to get things moving.

Another exercise used words suggested by the veterans and written up on the board.

“They chose the most beautiful words – faith, compassion, hope, optimism, peace, trust.

And I asked them to write a story using as many of the words as they liked to tell everyone a bit about themselves. They wrote some beautiful things.”

When Hilton asked people to read out their writing, one man who was really shy tentatively put his hand up and shared two things.

“A support worker told me afterwards that that guy had been coming to the group every day for two years and had hardly spoken, and today he’d stood up and read aloud. It was so Continued page 39 healthspeak Spring 2015

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alking into the Byron Shire Respite Service located inside Brunswick Heads Community Centre, the atmosphere is warm and friendly.

It’s Wednesday when HealthSpeak visits, the day when art therapy coordinator Karen Harborow encourages the centre’s dementia clients to put paintbrush to canvas. For those not inclined to paint, Sue, another worker is organising games of carpet bowls nearby.

The demands of caring for someone with dementia can impose a significant physical and emotional strain. The centre’s program operates Monday to Friday from 10am to 3pm and welcomes anyone classified with dementia or older people with compromised abilities a social day in a safe environment while their carer has a break from caring duties. Transport is available within the Byron Shire. Lunch and morning and afternoon tea are provided at a cost of $18 a day which can be negotiated if necessary.

Karen introduces me to a table of clients, I sit down and soon we are chatting away. They are finishing their lunch and looking forward to a creative couple of hours.

Karen has worked at the service for three years, initially as a volunteer and then as art therapy coordinator. With a background in film and television production design, Karen works six months a year in film and TV and the other six months working in the community.

A vibrant, engaging woman, Karen clearly enjoys her work.

We make our way around the centre as Karen explains the origins of various communal artworks and smaller individual pieces created by current and former clients.

“A lot of the people here might have done some art and craft but never really sunk their teeth into it. You can see some of the artworks here, little canvases, we start off slowly but surely.

“Then I brought a couple of

Spring 2015 healthspeak

Creative pursuits engage those with dementia

Top and right: Paintings from this year’s calendar.

Above: Karen guides clients to create their artworks.

really big canvases in and put them on the table.

I painted them black first, a good colour for people with dementia because they actually see their mark when they put a light colour on the darkness.

People would share the painting, there might have been six people around each canvas all sitting around doing their little bit. Then four canvases came together to be big artworks,” she explains.

Several large communal artworks are hung on the centre’s walls and they are quite spectacular with a riot of colour and design that come together

beautifully when the individual canvases are clustered together.

Karen explains that working in this communal manner, people’s confidence grows and they begin to develop their own individual styles.

The clients’ artworks also feature in a 2015 calendar produced by the Respite Service.

Those wanting to take a look or purchase one, can view it at http://byronrespite.com.au/ raffle.html Today at the centre people are working on their own pieces.

Some have individual pads in which they produce art each

a publication of North Coast Primary Health Network

week. Several clients proudly show me the many artworks they’ve created.

Watching the clients work, I can see they are absorbed and calm, clearly enjoying the process.

Karen talks about some of the clients at the table.

“Joan here was a graphic designer at some point, so in her day she would have made illustrations for advertisements, done water colour illustrations and hand lettering. But she’s not as interested in creating as that was work for her, so she’s happy colouring in without any pressure to produce something,” Karen explains.

“I’ve noticed that the people who never did art before in their lives are the ones that actually get a lot out of it now because it’s a release.

“We have Ned, a professional guitarist here who no longer has the dexterity in his fingers, but he’s obviously a creative soul and he’s taken up painting. Ned’s work has a real 1960s feel, some of what he creates could be fabric designs.”

Other clients at the table include Egyptian born Alma who is creating a floral design, Vince, an engineer who is drawing an impressive soccer game scenario, Joyce who is producing colourful abstract designs and Dot who tells me she used to enjoy painting landscapes, but has recently turned to modern designs.

“Working together at a table is an easy way of spending time together,” Karen says.

“Somebody might lean over and say ‘oh what are you doing?

And then the other person will say ‘I don’t know, it’s not mine, I didn’t paint it’ when they obviously did! But it’s a nice soothing, chatty atmosphere when people are working alongside each other.”

For more information on Byron Shire Respite Service phone Colin Munro on 6685 1921 or Barbara Chambers on 6685 1619.

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High risk non-melanoma skin cancer: How to spot the aggressive ones

By Dr John de Launey Consultant Dermatologist, Mid North Coast Specialist Outreach Clinic, Coffs Harbour

Sebaceous Carcinoma

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hile many common skin cancers can readily and appropriately be handled in a well-equipped general practice setting, others do require consideration of referral for advice or therapy. The criteria below help to identify such lesions. Some of these are very common and are seen in any family practice regularly. Some are rarer, but all are important to recognise. Dr de Launey welcomes queries or comments on the article, contact him on 6652 8820.

Squamous Cell Carcinoma

ALWAYS check and regularly review regional nodes for ANY SCC – none are 100% safe Lip, ear are sites with a significantly poorer prognosis >2cm diameter: 15% recurrence rate >4mm depth: 17% local recurrence, up to 45% metastasis rate (depending on site – lip worst) Poor differentiation SCC with perineural spread has 45%+ recurrence rate Acantholytic type SCC on pathology has a 14% metastasis rate, spindle cell SCC on pathology has a 25% metastasis rate; clear cell SCC pathology sub-type has a high recurrence rate The origin of the SCC may confer poor prognosis: arising in scar, radiotherapy area, burn, discoid lupus, leg ulcer, area of discharging osteomyelitis: all up to 30% metastasis rate Recurrent SCC has at least 20% recurrence rate, even if it has well-differentiated pathology

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Long Hx means more likely to recur or metastasise SCC in presence of immunosuppression: 12 - 15% metastasis rate Basal Cell Carcinoma

Morphoeic, infiltrative, micronodular types are more aggressive and have a higher recurrence rate – require more aggressive therapy Perineural invasion on histology – may spread along within nerve sheaths – on face may follow nerves through foramina into cranium Recurrent BCC has higher recurrence rate Immunosuppressed patient Canthus, nasolabial crease – higher recurrence rate, possibly because sometimes not treated aggressively enough in these surgically-difficult anatomical sites Auditory meatus: beware spread down the canal Merkel cell Carcinoma

Never a benign course with Merkel Cell Carcinoma <40 yo, male patient – much higher metastasis rate than older or female patient Head, neck poorer outlook Large lesion at diagnosis – poorer prognosis Small cell variant on pathology - usually significantly more rapid clinical course Vascular invasion >10 mitoses/HPF

25 – 33% recurrence, 25 – 30% metastasis rates; adjuvant radiotherapy Be aware of Muir-Torre syndrome, familial bowel cancer associated disease The diagnosis is a serious one – needs aggressive management, especially periorbital lesion >6mm size is a threshold size for higher recurrence rate >20mm diameter : 60% mortality Conjunctiva, multicentric lesions do badly Poor differentiation Vascular invasion, pagetoid spread DFSP (dermatofibrosarcoma protuberans)

25 – 50% recurrence with traditional surgery, reduced to 5% with Mohs’ surgery Recurrent DFSP has at least 60% recurrence rate Many mitoses Fibrosarcomatous changes on pathology MFH (malignant fibrous histiocytoma)

44% recur after surgery 40% overall have metastases 40% 2yr survival deep (fascia) – usually more rapid course >2cm diameter poor prognosis Less inflammatory histopathology - implies a more aggressive lesion Proximal location - poorer outlook Angioscarcoma

50% dead @ 15 months – most remaining will die within 3 years Associations with even poorer prognosis:

a publication of North Coast Primary Health Network

Stewart-Treves Children Post-RT Older patient with head and neck lesion The diagnosis itself is catastrophic Larger lesions progress more rapidly Microcystic Adnexal Carcinoma

Poor margins clinically associated with higher recurrence rate Nestlike and ductlike structures on pathology, or deep, sclerotic, perineural/vascular invasion, or presence of mucin on pathology will more often recur45% recur locally But no metastases!

Recurrence post-Mohs’ surgery very rare Recurrent lesions need aggressive management Extramammary Paget’s Disease

Recurrence/mets 33% recur, 20% even after Mohs’ – “skip” areas of seemingly disease-free tissue occur Mortality 45% with an underlying cancer died Associations underlying malignancy: bowel, breast, other High risk profile advanced local disease underlying cancer Perianal Paget’s Disease Dr John de Launey is a consultant dermatologist associated with the Skin and Cancer Foundation Australia and Melanoma Institute Australia. He teaches trainee dermatologists in surgical and diagnostic skills and has published papers on his specialty.

healthspeak Spring 2015

Feature

Child Protection: We Can Do Better All about Mandatory Reporting

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o mark Child Protection week - September 6 to 12, 2015 - HealthSpeak has compiled a feature to raise awareness about child protection and the important role of health professionals in reporting concerns about child abuse. The impetus for this feature came out of a meeting of the Children at Significant Risk of Harm Working Group from the Alliance for Services to Vulnerable Members of the Community. This Alliance is made up of representatives from North Coast Primary Health Network, Northern NSW Local Health District and FACS.

The Problem

The National Association for Prevention of Child Abuse and Neglect views child abuse and neglect as one of Australia’s most significant social problems. Last year more than 35,000 Australian children were proven to have been abused or neglected. Alarmingly, more than 7,200 children were found to be at risk of significant harm on the North Coast of NSW during 2013/14 (Mid North Coast 3,018 and Northern NSW 4,251.)

What is Abuse?

The Australian Institute of Family Studies (AIFS) defines various forms of child abuse: Physical abuse: nonaccidental aggressive act towards a child including hitting with an object, shaking, punching, kicking etc.

Psychological abuse: includes rejecting, ignoring, terrorising and/or not providing emotional support and care.

Spring 2015 healthspeak

At risk situations Adults misusing

substances or alcohol

Adults with mental health issues

Children in homes where domestic violence occurs

Sexual abuse: any sexual activity between a child and an adult or older person. Includes fondling, oral or anal and vaginal penetration, exposing or involving a child in pornography, voyeurism etc.

Neglect: failure to provide for a child’s basic needs, including not enough food, shelter, clothing, supervision, medical attention etc.

Family Violence: a child being present, either hearing or seeing, while a parent or sibling is subjected to physical, sexual or psychological abuse or is exposed to damage caused by the abuser.

When is a child at risk?

In NSW a child (aged 0 to 16) is considered at risk of significant harm if concerns exist for the safety, welfare or wellbeing of the child because of the presence to a significant extent of Basic physical/psychological needs not being met Carer failing to arrange medical care Carer failing to arrange child’s education Physical or sexual abuse Living in a domestic violence situation Child being seriously psychologically harmed Child was subject of a prenatal report and birth

Report suspected child abuse. Call 13 36 27 mother failed to engage with services

7269 kids were found at risk of significant harm on the North Coast in 2013/14

Possible signs of neglect

low weight for age and/or failure to thrive untreated physical problems e.g. sores, serious nappy rash and urine scalds, significant dental decay poor standards of hygiene i.e. child consistently unwashed failure to provide medical care lack of supervision/being left with unsafe carers poor school attendance Possible signs of physical

Continued next page

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abuse bruising to face, head or neck bruising in non-mobile infant drowsiness, vomiting, fits which may suggest head injury adult bite marks suspicious/unexplained fractures, especially under two years of age burns and scalds multiple injuries or bruises, lacerations or welts excessive aggression/hypervigilance frightened of, or overly compliant with carer Feature

Reports by health professionals make up only 13% of all reports

Possible signs of sexual abuse

Child Protection: We can do Better

disclosure of abuse bruising or bleeding in the genital area sexually transmitted diseases bruising to breasts, buttocks, lower abdomen or thighs adolescent pregnancy self harm, suicide attempts sexually aggressive/explicit behaviours/drawings/play

What are reasonable grounds?

You do not need to have proof to report concerns about the safety of a child. Indicators that represent reasonable grounds to report a suspected offence include: A child discloses that he or she has suffered or is suffering non accidental physical injury or sexual abuse Someone else advises you that a child has been sexually abused or non-accidentally injured, or Your own observations of the child’s physical condition or behaviours lead you to reasonably suspect that the child has suffered or is suffering non-accidental physical injury or sexual abuse.

Possible signs of psychological harm

Poor self esteem/withdrawn Few friends Self-harming behaviours Living in domestic violence

Reporting responsibility

The law (NSW Children and Young Person’s Care and Protection Act 1998) requires that every health worker reports suspected child abuse. As a health professional, if you have reasonable grounds to suspect that a child is at risk of significant harm you must report it.

Under the law you are protected from prosecution if you make a child abuse report in good faith.

You do not need to establish that child abuse is occurring, just report your suspicions and FACS will investigate.

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Tamahra Manson, Senior Health Clinician, Northern Rivers Joint Investigation Response Team.

Benefits of reporting

The laws help to create a more child-centred culture which will not tolerate serious abuse and neglect of vulnerable children. Research has found that mandated reporters make a substantial contribution to child protection and family welfare.

Rosa Flaherty, Child Protection Manager, NNSWLHD, told HealthSpeak that the role of the GP in child wellbeing had become more prominent over the past 15 years in NSW. She

a publication of North a publication Coast Primary of North Health CoastNetwork Primary Health Network

said this was due to changes in legislation and initiatives such as the Keep Them Safe reform – the government’s response to a special commission of inquiry into child abuse in 2008.

“The curious thing with child abuse is that even though the laws and policy directives are very clear on who is required to report suspected child abuse, the practice of reporting is still ad hoc,” said Rosa.

Aboriginal children

Abuse occurring in Aboriginal communities poses particular challenges.

Nationally, the number of identified children at risk living in out of home care (OOHC) has risen each year from 2010 to 2014. There were 43,009 children in OOHC on 30 June 2014, which equates to a rate of 8.1 per 1,000 Australian children. At 30 June 2014, there were 14,991 Aboriginal and Torres Strait Islander children in OOHC, a rate of 51.4 per 1,000 Indigenous children. The national rate of Indigenous children in OOHC was almost 10 times the rate of other children.

Tamahra Manson said that despite the over-representation of Aboriginal children reported to be at risk, more reports could be made by health professionals working with Aboriginal children, young people and families.

Serious abuse tends to be under reported.

A recent conference on child protection at Casino, hosted by the Joint Investigation Response Team, heard the opinion from police that a different strategy is required to combat child abuse within Aboriginal communities.

The two-day conference involving around 50 community members, social workers and educators from remote areas, raised concerns that child sexual and physical abuse was underreported in communities such as Tabulam, Casino, Woodenbong, and the Mulli area.

The conference heard how children fear retribution and

healthspeak Spring 2015

Feature

‘loss of family’ if they speak out about abuse, and how power is used to silence children, with senior community members often using their stature to manipulate the vulnerable.

Inspector Nicole Bruce, from the Richmond Local Area Command, said the problem was not necessarily bigger in those communities, but it was difficult to gauge the true extent because nobody talks.

“Historically within the Aboriginal community there are a lot of barriers that have built up and a lot of myths to dispel. The obvious one is that when you report something, the welfare is going to take you away, and that’s simply not the case these days,” she added.

Health professionals should keep a close watch on children and young people from all families. Tamahra outlined a few scenarios where children and young people were at risk.

1) Adults misusing substances or alcohol 2) Adults with mental health issues 3) Children in domestic violence

Other worrying situations that are often overlooked are young people engaging in sexual activity.

“In NSW the law says you can’t have sex until you are 16. Young women might be presenting pregnant or wanting information about terminations or contraception. It is really important that health professionals are asking questions about what’s going on, because a young person might present and say they’re engaging in peer consensual sexual activity but that might not actually be the case.

Tamahra said the third area of concern was particularly tricky – sibling sexual abuse.

“We know the incidence is much higher than reported, we

Spring 2015 healthspeak

know it’s often an indicator of other child protection concerns.

People might present to GPs concerned about sexual activity going on that they know of or suspect between their children.

That is really important stuff to be reported.

“We want to interrupt that sexually harmful behaviour between siblings and get them the right services, but we also need to know what’s going on in this family that’s led to that happening,” she said.

Report the smallest thing

The important role that health professionals play in reporting child abuse cannot be overstated. Tamahra stressed that even the smallest piece of information could be vital.

“It’s important to remember that the piece of information you’ve got comprises one small piece of a bigger child protection jigsaw puzzle. Someone might think ‘what I’ve got is not that significant’, but the GP or someone else might have the very piece that FACS need.

“What happens is the GP might have a piece of informa-

tion, the school teacher might have a piece of information, the speech therapist might have another piece and slowly the full picture becomes clear. So a person might think that what they have is not enough, that FACS aren’t going to do anything with it.

“But keep in mind that your piece of information is going to form a broader history for Community Services which then assists them in terms of allocating priorities,” Tamahra explained.

Report the smallest thing, one piece of information could be vital

Failing to report

In a review of reporting behaviour published this year, Debbie Scott and Jennifer Fraser wrote that in Australia reports of children at risk by health professionals accounted for only 13.5% of all reports lodged. (Reference available on request.)

Rosa Flaherty said the authors of the review had concerns that health workers might not view child protection as part of their role and might see other professionals as being more Continued page 34

a publication of North a publication Coast Primary of North Health CoastNetwork Primary Health Network

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Child Protection: We can do Better

At risk situations

Birthing model hailed as ‘top research’ D

irector of the University Centre for Rural Health (UCRH), Professor Lesley Barclay AO, who is also a Board member of North Coast Primary Health Network, has been recognised for leading one of Australia’s top 10 research projects over the past year.

The Ten of the Best Research Projects 2014 were selected for their innovation and potential to make a difference to people’s lives.

Professor Barclay’s team conducted extensive research on birthing practices in rural and remote communities in the Northern Territory’s Top End. This led to the rollout of a model of care that is delivering significant benefits for Aboriginal mothers and their babies.

“The benefits include improved care for mothers with potential for increased birth weights for infants,” said Prof Barclay who began her career as a midwife.

“At present, Aboriginal and Torres Strait Islander women still have a higher maternal mortality rate than women in Sri Lanka or Malaysia, with twice as many Indigenous babies (11% in total) being of a lower birth weight than the general Australian population. “ The research was supported by the National Health and Medical Research Council (NHMRC). The work started when Professor Barclay was at Charles Darwin University and was completed at the University of Sydney.

“While most Australian mothers in urban centres have access to high quality maternity and infant care, those living in rural and remote Australia aren’t so lucky, and Indigenous Australian mothers in these locations are at a particular disadvantage,” Prof Barclay added.

“Based on my own experience and the research findings, it was clear that too many women were 28

missing out on proper evidencebased care, while the care they did receive was delivered in ways that weren’t respectful to women, and were not familycentred.”

The research was carried out in two large remote communities in the Territory’s Top End, and their regional centre. It included lengthy observations, dozens of interviews and the study of hundreds of mother infant records.

The results led to a range of improvements, the most significant being the Midwifery Group Practice (MGP) model, which provides a continuity of care where one known midwife provides pregnancy, birth and post birth services.

Professor Barclay and her team are now working to develop the Australian Regional Birthing Index, a version of a calculation designed by Canadian researchers.

Professor Lesley Barclay

Port Macquarie: becoming a Dementia-Friendly Community

St Agnes’ Parish CEO Adam Spencer, Kara Nicholson and Father Leo Donnelly

P

ort Macquarie is a step closer to being a Dementia-Friendly community, with the first three businesses approved to work towards becoming DementiaFriendly community where people living with dementia are supported to live a high quality of life with meaning, purpose and value.

Port Macquarie has the third highest prevalence of dementia in NSW (1730 people) and now is the time for community and businesses to act.

Coast Front Realty became the first business to work towards being a DementiaFriendly business in July. The changes that they undertook

were small, simple and manageable - painting the bathroom door a different colour to the walls and providing dementia specific education to staff. This process is not meant to be onerous or costly to businesses, said Alzheimer’s Australia NSW DementiaFriendly Community Project Officer, Kara Nicholson.

St Agnes’ Parish and Silver Service Hire Cars were next to embrace the program, making changes to ensure inclusion for all community members.

St Agnes’ Parish provides services including early education, schools, aged care, social welfare and pastoral ministries.

They will be providing de-

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ment ia specific education to staff and have partnered with Alzheimer’s Australia NSW to run the volunteer social engagement program, Dementia Mates. In addition, beginning with their Hostel, they will use the dementia-friendly audit tool to review the physical environments of each facility.

Silver Service Hire Cars’ Action Plan includes providing dementia specific education to staff, a review of car interiors using the dementia-friendly check list, the creation of a dementiafriendly booking process.

Included in the strategy is the Dementia Action Alliance, a body approving DementiaFriendly Business Action Plans.

“If as a collective we can have a greater understanding of dementia and an ability to be able to respond to the needs of those people with dementia living in the community, it can only be a positive step,” said Kara.

For more information on the program or if you are interested in your business becoming Dementia-Friendly, contact Kara at kara. nicholson@alzheimers.org.au

healthspeak Spring 2015

HIV Treatment – a New World

By Dr David Smith Medical Director, Lismore Sexual Health Service

R

ecent advances in the treatment of HIV infection and the benefits these confer for those with the infection and those at risk of acquiring the infection, have heralded a new world for this previously uniformly fatal condition.

Single tablet regimens (STR)

Treatment of HIV became successful in the mid-1990s but difficulties including multiple dosing schedules, handfuls of tablets and significant adverse events made life difficult for those infected and their carers.

By the late 2000s the first STR was released and in April the fourth of these was released, unimagined in the early dark years of the epidemic. Along with this simplification, regimens have much improved tolerability, and most importantly efficacy and durability. Whilst various factors mean STRs are not for everyone, most regimens are now once daily, sometimes twice daily and involve few pills.

Durability and potency of the medications along with treatment adherence on the part of those infected are vital for viral control and long term success.

These modern drugs certainly provide the former and assist with willingness to adhere, but many patients are still taking regimens started 15 years ago.

A popular regimen of the late 90’s involving three pills twice daily is now taken as two pills once daily with no loss of viral control over that period and restoration to essentially normal immune function. The majority of people living with HIV (PLWH) will die with, rather than of their infection.

medicolegal risks for doctors due to misadventure. They are numerous and unpredictable. Significant examples include alterations in drug metabolism such as prescribed and over the counter inhaled steroids and injected depot steroids leading to adrenal shutdown and rhabdomyolysis with statins in PLWHA taking drugs that inhibit the CYP 450 or Pgp enzyme systems.

Cardiac arrhythmias occur in patients prescribed erythromy-

it their antiviral activity. Lismore Sexual Health Service is happy to field calls at any time or DDIs can be researched at an easy to use Newcastle UK website: www. hiv-druginteractions.org Treatment as Prevention (TasP)

Two landmark studies published over the last three years demonstrate that suppression of the virus in PLWH essentially eliminates onward transmission

STI Screening in men who have sex with men:

Sexually transmitted infections increase risk of HIV infection Six-monthly testing, more often if highly sexually active HIV Antibody Syphilis test (RPR for those previously treated) Hepatitis A (vaccination recommended if non-immune) Hepatitis B (vaccination recommended if non-immune) Hepatitis C (in those injecting drugs or HIV positive) Throat swab – gonorrhoea and chlamydia PCR Anal swab – gonorrhoea and chlamydia PCR First void urine or urethral swab – chlamydia PCR

cin and taking protease inhibitors that may prolong the QTc interval. Loss of viral control can occur in patients prescribed H2 antagonists or proton pump inhibitors and taking HIV medications that require an acid environment for absorption. The use of cations such as Ca, Mg, Zn and Fe that bind to the active site of Integrase Inhibitors will inhib-

of the virus to sexual partners, whether extra protection (condoms) is used or not. HPTN052, released in July 2011, demonstrated >96% effectiveness in reduction of transmission to the uninfected partner. This was mostly in heterosexual couples.

The PARTNER study, early data from which was released in March 2014, demonstrated zero

Drug/Drug interactions

DDIs continue to pose risks for those infected with the virus and Spring 2015 healthspeak

linked transmissions between homosexual partners with the full study results to be released in 2017. Statistical analysis predicts >96% protection also.

Pre (PrEP) and Post (PEP) Exposure Prophylaxis

Evidence is mounting that the use of antiretroviral drugs in those not infected but at risk, both prior to and after a risk event, significantly reduce infection rates. PEP starter packs are available through all local Emergency Departments for those presenting within 72 hours of a risk event - guidelines inform the suitability of an attendee for this.

PrEP will become available in the near future as part of the NSW HIV Strategy through participating public clinics.

NSW HIV Strategy

The ambitious goal of this strategy is to decrease new HIV infections by 80% by 2020. To that end there is a three-pronged approach. Firstly, identify those already infected with the virus who are unaware of the infection.

This has involved ramping up testing rates, including reaching those who have not or who are reluctant to test. and includes such initiatives as Point of Care testing outside traditional clinical venues and key performance indicators for publicly funded services. Home based testing is soon to be made available.

Secondly, early treatment initiation, after appropriate patient discussion and agreement to improve long term outcomes for the patient and decrease onward transmission of the virus to sexual contacts. Thirdly, the strengthening of education measures currently employed to reduce transmission such as encouraging the use of condoms and clean drug injecting equipment, and now the TasP, PEP and PrEP messages.

Continued page 30

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What’s new in overactive bladder treatment?

By Dr Kenny Low

O

veractive bladder (OAB) is a common condition affecting up to 1 in 6 people.

It is characterised by urinary urgency, urinary frequency and nocturia. Urge urinary incontinence is often found in more severe cases.

Conventional management for overactive bladder has been to avoid bladder irritants, “retrain” the bladder and anti-cholinergic/antimuscarinic medications. Unfortunately, the medications have troublesome side-effects (such as dry mouth and constipation) and lack of efficacy in a significant proportion of the population. The oral medications will alleviate some but not all of the symptoms.

Botox/botulinum toxin type A, has been used for many years for a number of neurological, pain and movement disorders. As of 1 November 2014, Botox has been PBS approved for use by “Botox qualified urologists and urogynaecologists” in the treatment of idiopathic overactive bladder. Botox improves bladder capacity and continence by

reducing bladder contractions and decreasing the sensation of urgency.

It is a simple day procedure to administer Botox. The Botox is injected through a cystoscope into the bladder wall. The major side-effect is the potential for poor bladder emptying requiring self catheterisation (occurring in about 5% of patients). This sideeffect is reversible with time. Most patients with severe overactive bladder would much prefer to self-catheterise (and choose the

800 students at PASH 2015

time of voiding) rather than having a urine storage problem.

North Coast Urology is very excited about this development. Patients no longer need to pay for the Botox medication should they be offered this treatment (that is, Botox is now a PBS medication should patients fulfil the prescribing criteria).

St Vincent’s Private Hospital in Lismore has already done a number of PBS subsidised intravesical Botox cases with excellent results as expected from previous experience.

Patients usually see an improvement within two weeks and the effect typically lasts 6 to 9 months.

Repeat injections of Botox are usually required when the effect wears off. Repeat injections are as efficacious and there appears to be no long-term side-effects.

Urologist Dr Kenny Low would be most happy to help if you have patients currently poorly responding to conventional overactive bladder treatment. Phone him on 6622 2062.

lent questions from students including one asking GP Natalie how to make an appointment with a doctor and whether the consultation was confidential or not – would the young person’s parents be told? Hot topics discussed at the forum included STIs, Transgender issues, IntiFrom page 29

HIV Support Program (HIVSP) The Community Panel answers questions at PASH.

T

he second PASH – a free regional two-day sexual health conference held in June for young people aged 15 and over was a lively, engaging event with students from 18 schools between The Tweed and Grafton attending.

PASH enables young people to build their confidence, skills, resilience and knowledge of sex, sexuality, sexual health and sexual health services. Run by a consortium of 32 North Coast youth, education and health 30

organisations, North Coast Primary Health Network is a proud sponsor of this youth event.

HealthSpeak dropped in on PASH at the Byron Bay Sport and Cultural Centre and sat in on the community forum where presenters summed up their experience of the conference and invited questions. The presenters included a doctor, lawyer, psychologist, rap artist/teacher/ doctor and members of Byron Youth Council.

There were some excel-

GPs are urged to lower their threshold of risk assessment for HIV and test more often.

While men who have sex with men are most at risk of infection, significant numbers of those from and those travelling to high prevalence countries are being diagnosed with the infection. The HIVSP initiative aims to support GPs, with little experience in HIV to deliver a new positive result to a patient and achieve the best outcome. NSW Health is notified of a new diagnosis

a publication of North Coast Primary Health Network

macy and Sex and the Law. On the final day of PASH, some members of Keeping our Mob Strong, who had attended workshops to write and rehearse songs about sex with well known Indigenous rap artists The Last Kinection performed to an appreciative audience. by the laboratory and informs the local HIVSP coordinator who will contact the GP to offer support, information and management pathways for both the doctor and the patient.

This is a brave new world for those infected with the virus and those at risk. Viral control restores the immune system and allows resumption of a full, active life with few restrictions. HIV infection is now a chronically manageable infection requiring the same planning as that involved in caring for other similarly long term conditions.

healthspeak Spring 2015

The GFC: What have we learned?

O

n Thursday, August 9, 2007 the Paris-based global bank, BNP Paribas, froze three of its funds claiming it could not value some weirdsounding assets it had acquired called collateralised debt obligations (CDOs). That day, the world changed.

BNP Paribus was the first major bank to acknowledge the risk of CDOs - bundled collections of sub-prime mortgages made to dubious credit-worthy homebuyers in the US and sold to investors world-wide.

Just over a year later, Lehman Brothers, one of the largest investment banks in the world - and one heavily involved in CDOs - filed for bankruptcy.

The financial world panicked and the Global Financial Crisis (GFC) was upon us. More than eight years later its effects are everywhere.

Trillions and trillions of dollars in potential output has been lost, lives have been ruined, businesses have gone bankrupt, indebted countries are at risk of failing and in some countries a whole generation may face permanent unemployment.

Social unrest is rising. The GFC was disastrous for developed countries.

The only consolation is that it might have been worse. We could have been plunged into another worldwide depression.

So what have we learned? What caused the crisis and is it likely to happen again? Will things go back to the way they were?

One major lesson is this: free market capitalism is dead â&#x20AC;&#x201C; although not everyone agrees and some are trying to revive the corpse. For three decades the apostles of liberalisation and free market economics have been dominant in world policy-making. Think Thatcher and Reagan,

Spring 2015 healthspeak

Abbott and Howard and even Hawke and Keating in a limited way.

At its most fundamental level this libertarian philosophy believes in the autonomous and self-reliant person and rejects any form of social or collective action. This philosophy spread to infiltrate the financial and economic sectors of western economies and increasingly in the east as well. Markets, they believe, are the best way to allocate resources. There was also an inherent belief that markets were

banks who tore up the regulations that had been imposed after the aftermath of the 1930s Great Depression.

These officials believed they had it sorted with mathematical models to prove it.

When the crisis hit, the trust in free markets evaporated - except amongst the libertarian diehards. Governments intervened, rescued the banks and pumped money into their economies.

Regulations have been reintroduced, banks have been forced to meet new capital re-

quirements and limits placed on bonuses and incentives. But will it be enough to stop another crisis? According to many analysts the answer is no. Our financial system is designed to fail.

Banks borrow short-term liquid assets in the form of deposits and use them to invest in long term, risky assets that are illiquid. In a time of crisis the depositors and other bank lenders want their money back - but all cannot be accommodated.

Banks are then faced with a liquidity and a solvency crisis as their risky assets plunge in value.

To try and prevent catastro-

phe governments are forced to intervene.

But because of the huge debts incurred by governments in the latest rescue, their ability to intervene again is limited. But will we be able to eventually get back to the way things were? Again the answer is probably no.

Large macroeconomic and social forces have changed economies around the world.

In the west growth rates are likely to be much slower than before because the population is ageing and demand is falling due to growing inequality. As we know the workforce will decline.

This means average incomes will decline (fewer workers, more mouths to feed) unless we can convince the young to work harder and more productively.

In addition the libertarian economic philosophy â&#x20AC;&#x201C; free trade, less regulation, flexible work force - has helped the spread of globalisation. While this has seen rapid growth in emerging economies, it has led to drastically higher income inequality in most developed countries. While highly trained people have done well, many jobs in the unskilled or semiskilled area have been automated or outsourced overseas.

Because the rich spend a smaller proportion of their incomes (and save more), there is an overall fall in demand and consequently even higher unemployment. Are there any solutions?

Yes, we need a drastic change in the financial sector and a concerted effort to redistribute income. But we will probably have to endure another crisis before there is enough momentum for this sort of change.

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31

Invasive species Fact Sheet

Common name: Area affected: Cause: Impact: Control:

finance David Tomlinson

The Wolf of Wall Street Global Free Market Capitalism Exploits the Free Market to take advantage of the human populace for own financial gain Drastic change in Financial Sect or

d

self-correcting, efficient and stable. Well, the GFC proved this wrong.

While a number of events contributed to the crisis, its seeds were born and nurtured by the financial system itself.

The libertarian philosophy promoted a generation of financial gurus who indulged in excessive risk taking, promoted everhigher levels of debt and created complex financial products even they did not understand. There was unbelievable greed and even fraud.

They were assisted by government officials and the central

Vascular Surgery: Big changes within two decades

By Dr Deepak Williams Vascular Surgeon – North Coast Vascular

I

first saw Star Trek when I was in medical school and was always fascinated by the gadget “Doc” had. This hand held gadget could make a diagnosis and treat at the same time; I used to wonder whether I would ever be able to see anything like that in my life time.

After finishing medical school in India, I went off to England where I did my general surgical training. In those days vascular surgery was a part of general surgery. Both in India and in New Zealand vascular surgery was essentially open surgery.

We used to dissect everything out, control, clean, patch or bypass. We repaired abdominal aortic aneurysms by suturing grafts inside the aneurysm sac.

These were big operations and used to have significant morbidity for the patients.

My first exposure to endovascular intervention was in 2001 when I started my Fellowship in vascular surgery in Melbourne.

There I was trained in the nuances of endovascular intervention by some of the pioneers of endovascular intervention in this country. Even in those days only easy abdominal aortic aneurysms used to be treated with a stent graft and only easy lesions in the lower limb arteries with balloon angioplasty.

When I started practising in Lismore in 2004, the majority of my practice was open vascular surgery. We used to do a handful of endoluminal stent grafts and a handful of angioplasties every year. Our wards used to be full of patients who had had bypasses done and they used to spend a long time in the Hospital. The morbidity and mortality of those procedures was quite significant.

Then in 2005/2006 endovascular intervention suddenly 32

took off, and now the majority of my practice is endovascular and only those patients that can’t be treated endovascularly we treat them with open surgery.

The treatment of occlusive arterial disease has changed dramatically over the years. We now regularly treat long lesions, sometimes including the whole length of the superficial femoral artery and the popliteal artery.

We do subintimal angioplasty to open these arteries and then once those arteries have been opened the main battle is how to keep them open.

A few years ago stents where all the rage and we soon realised that in lower limb arteries stents only have definite lifespan. Once a stent blocks then the endovascular options are limited and patients then need open surgery.

However, since the advent of Drug Eluting Balloons 2 years ago; that trend is also now changing.

Drug Eluting Balloons have an anti-cancer drug like “Paclitaxel” coated on them and once the balloon is expanded in the artery, the drug is left behind on the walls of the artery. This drug then reduces the degree of scarring and neo intimal hyperplasia in those arteries. Nowadays we are trending away from using stents in lower limb arteries; and if we do use stents they are either

The trend is moving away from leaving anything in the artery except drugs drug eluting stents or covered stents which are coated with PTFE. On the whole, the trend is moving away from leaving anything in the artery at all, except drugs.

Amputation rates have decreased significantly and we are keeping more limbs attached for longer periods of time. The main challenge in occlusive disease is now Diabetes, which affects the arteries below the knees.

Nowadays we do tibial recanalisation on a routine basis. It is quite common to go down and balloon angioplasty arteries right down into the foot. With new devices coming out on a regular basis it is becoming difficult to keep up with the technology but our ability to revascularise lower limbs has increased significantly.

In those patients where endovascular intervention has failed we use hybrid technology which is a combination of open surgery and endovascular intervention.

Last year St Vincent’s Hospital

a publication of North Coast Primary Health Network

in Lismore took the bold step of opening a Hybrid theatre which was the first of its kind in regional Australia.

Again, we at St Vincent’s Private Hospital in Lismore are at the forefront of this technology. Recently we used a new TriVascular Ovation Stent Graft for a difficult aneurysm. This was the fourth such device implanted in Australia, the first being implanted at St Vincent’s Hospital in Sydney. Again it was the first time this device was used in a regional hospital in Australia.

As for aneurysmal disease, the majority of the abdominal aortic aneurysms and popliteal artery aneurysms are treated with endovascular means. The main determining factor of whether an aneurysm can be treated endovascularly was its anatomy, and now with the new devices in the market that too is becoming a thing of the past.

Similarly, for venous disease, endovenous ablation is on the rise and due to financial restraints it’s only available to private patients in Lismore, whereas public patients still undergo open vein surgery.

This does not mean that this is the end of open surgery for certain arteries like carotid arteries.

Open surgery is still the “gold” standard, and we in Lismore have some of the lowest complication rates around the country for this operation. Open surgery is still reserved for patients with other problems which cannot be treated with endovascular means.

It is pleasing to see how far surgical techniques have advanced and with them the corresponding reduction in complications and morbidity.

Hence, I am happy to report that the “Enterprise” is in good shape and is moving at warp speeds towards new horizons.

So, Goodbye and God bless for the moment, till our next report from a Galaxy far far away. healthspeak Spring 2015

In search of the perfect cuppa I

t’s a long way to London so we decided to break our flight in Sri Lanka. Our ‘break’ turned into 17 days.

Sri Lanka is about the size of Tasmania but it has the same population as all of Australia.

The comparison ends there. It’s a land full of surprises As a tourist it’s tempting to contrast this to the Indian experience. It’s in the same subcontinent after all, but this teardrop shaped island seems quite unconscious of its mighty neighbour to the near North, although an impending cricket match between them is causing much excitement. We’ve arrived in Galle, on the southern coast, where the 2004 tsunami wreaked havoc, killing 37,000 people. The cricket ground needed restoration and it’s here that the big match is being held.

Travellers say it’s easier and cheaper than India. In my brief encounter, transport and lodging are about half the Australian price. Food is so cheap and delicious it’s ridiculous and so far so good in the digestive tract.

Beggars and touts are not in such overwhelming numbers and Sacred Cows don’t strut so proudly around. Oddly enough, dogs are tolerated. They lie on the busy roads and don’t get run over. Dog buffs would be surprised at the self-possession of these animals, how without apparent owners they take themselves off for seemingly purposeful walks.

It’s notable that Hindu, Muslim, Christian and Buddhist people all seem to exist in harmony.

As a blow-in to this complex land a disclaimer is in order as I really don’t know anything.

My informants are mostly tuk-tuk drivers and waiters. I have only encountered friendliSpring 2015 healthspeak

ness but nobody speaks of the terrible ‘troubles’, only glad they’re over.

An old advertising slogan triggers a childhood memory. ‘The teas that please are Ceylonese’.

Today’s Sri Lankans continue in this steadfast pride of their tea and the country is steeped in it.

A sage friend called Brian from Australia will not accept a cup made with a teabag. So it is here, served in a pot, no teabag.

His eccentricity seemed a bit extreme. Now, I see this humble commodity in a new light.

A visit to the Kandy Tea Museum opens the story. An attempt to grow coffee was foiled by a rust fungus galloping through that monoculture.

Then, a resourceful young Scot, James Taylor, rescued the economy by planting seeds of Camelia Sinenis he had imported from India in 1867 and the rest is history. Surprise! Tea is a member of the Camelia family!

Taylor’s memory is so revered that little pieces of his life are rendered under glass, including a child’s broken plate inscribed : ‘If the fairies came to tea How very jolly that would be.

They’d say “Hullo.”

I’d say “Come in” And then the fun would all begin’.

Perhaps the dour Scot was a kid at heart.

He introduced the process, still in use, so that black tea could be exported to the motherland. Others followed and made fortunes, most famously the sailor, Sir Thomas Lipton.

Tamil people were indentured from southern India as a massive labour force to clear the high country of jungle. The hardships and suffering are only hinted at in the museum. The sole surviving tattered goat hair ‘Cumbly Blanket’ on display is the only

clue.

‘It was used by pluckers as protection against rain, against cold and it served as a mat to sleep on, as a cradle with an inner cover to rock infants to sleep’.

A modern person looking over undulating acres of tightly manicured bushes might wonder what happened to elephants, butterflies and other species during the tea rush 150 years ago.

The complexity of tea varieties creates discussion to rival the clinking of Dr Ingall’s wine bottles. From the prized White Silver Tips, Broken Orange Pekoe down to dust grade tea bags, expert tasters at the tea factory are vigilant so that quality is assured for tea lovers the world over.

Sage Brian says of tea: ‘cheap, refreshing and legal’.

But is it healthy? Opinions vary, except in Sri Lanka.

a publication of North Coast Primary Health Network

light airs David Miller

The complexity of tea varieties creates discussion to rival the clinking of Dr Ingall’s wine bottles

33

From page 27

responsible for these – eg social workers, police, teachers etc.

“One of the reasons Scott and Fraser give for this low level of reporting among health professionals is lack of access to training. Many health workers know the reporting procedure but might have fears that stop them from reporting,” said Rosa.

Tamahra Manson shed further light on the low numbers of health professionals reporting.

“Research tells us that there are three main reasons for health professionals failing to report. First, that it can have an impact on their relationship with their patient; secondly, lots of people feel like ‘what’s the point?’, FACS don’t do anything anyway; and lastly, a lot of people don’t know what the requirements are,” said Tamahra.

Another reason for failing to report, according to Tamahra, is that professionals feel that ‘someone else’ will make the report.

“And usually that ‘someone else’ doesn’t make the report.

We’ve had a number of investigations here where babies have received very serious, life threatening injuries where health workers have failed to report they were at risk of harm.

Failure to report does result in injury to children,” she warned.

Community Paediatrician Dr Jackie Andrews, who’s based in Lismore, told HealthSpeak that she always advises GPs that if they have any misgivings about a child to go ahead and report the situation. She wants doctors to understand that they are powerful advocates for a child.

“I say to them, how would you feel if you didn’t make a report and two weeks later that child ended up in hospital with serious injuries or injuries resulting in death? Always make a report.

“GPs are the family doctor and they’re in a ringside seat to view the family situation.

They know what’s going on in a family, as they get to know both children and parents. It’s

Feature

If you have misgivings about a child, go ahead and report. Call 13 36 27

Child Protection: We can do Better 34

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the job of a GP to make a report and if you make the report and FACS are unable to act because of limited resources or make a decision not to take action based on other information, then rest assured you did all you could,” said Jackie.

Rosa Flaherty also wanted to stress the key role GPs, nurses and allied health professionals on the North Coast can play in child protection.

“For example, if a GP is assessing a child’s respiratory complaint and that child appears to be unkempt, underweight and hypervigilant about the carer’s behaviour during the consult, the GP might well be concerned about neglect and/or physical abuse.”

au/mrg/screen/DoCS/en-GB/ summary?user=guest The Mandatory Reporter Guide is a step by step process walking a person through what they need to do.

The HealthPathways website has also set up a referral pathway for reporting child abuse.

You can find it here: https:// manc.healthpathways.org. au/88091.htm The username is manchealth and the password is conn3ct3d Busy GPs can also make a verbal report to the Helpline or make a faxed or electronic report.

If you need to report an offence that requires immediate police attention, call Police on 000.

How do I report?

What will FACS do?

You can make a report by phoning the NSW Family and Community Services (FACS) Child Protection Helpline on 133 627. Since January 24, 2014 mandatory reporters have been encouraged to use the Mandatory Reporter Guide, to guide their decision making and determine whether or not to report to the Child Protection Helpline under the new risk of significant harm reporting threshold.

You can find the NSW Mandatory Reporter Guide here: http://sdm.community.nsw.gov.

In response to a mandatory report, FACS will conduct an assessment of the risk of significant harm to the child. Depending on the circumstances, this might include asking further questions of you, contacting government agencies such as Education, Health or Police or the child’s teachers. Where there are concerns that the child is in danger, the child’s family may be visited immediately.

Resources Keep Them Safe www.keepthemsafe.nsw.gov.au/ NSW Mandatory Reporter Guide http://sdm.community.nsw.gov.au/mrg/screen/DoCS/en-GB/ summary?user=guest E-Reporting https://kidsreport.facs.nsw.gov.au/captchaImagePROD/ default.aspx Frequently Asked Questions http://www.keepthemsafe.nsw.gov.au/resources/frequently_ asked_questions Rosie Batty on how doctors can help https://www.mja.com. au.acs.hcn.com.au/homepage_launch?0=ip_login_no_cache %3D1cc702423ae9b91926a12927308a5345

a publication of North a publication Coast Primary of North Health CoastNetwork Primary Health Network

healthspeak Spring 2015

Emergency Dr Simon Judkins (Ed.) Penguin 260pp $32.99

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lot has changed in emergency medicine since I took a position in ‘Accident and Emergency’, as it was called then,” writes Dr Edward Brentnall, Founding Fellow of the Australasian College for Emergency Medicine (ACEM), in his afterword to this collection of ‘real stories from Australia’s emergency department doctors’.

As recently as 1975, there was no ACEM, no EDs in the sense that we know them today, nor a Medicare scheme. Only the ‘less well-off patients’ were given free treatment, with others expected to access a GP unless they had a real emergency.

In the foreword, ACEM president Dr Anthony Cross outlines how these stories tell of “the real challenges, triumphs and heartbreak of providing emergency medical care in Australian hospitals,” adding, “In the ED, every day is extraordinary”.

He expresses the hope that the diverse contributions will make readers laugh, cry and even learn a little, and we are not to be disappointed, with the editor, Dr Simon Judkins, leading us through an array of fascinating, heart warming, and sometimes tragic cases.

They are grouped as ‘Life and Death’, ‘Family Matters’, ‘A Day in the ED’ [“A typical shift in the ED, from inner-city Melbourne to Cape Town and Papua New Guinea”], and ‘Our Doctors’.

Although he received input from 25 other contributors, this book belongs significantly to Dr Judkins who penned a number of the essays as well as the introductory note, explaining that the initial spark was the response to his story “24 hours in the ED”, written to help colleagues better understand EDs, and the teams who run them.

“The feedback I received was fantastic. This made me realise just how little the wider community (even those working Spring 2015 healthspeak

book review Robin Osborne elsewhere in the health sector) knows about emergency departments. It also made me realise that our work is full of human stories - some of celebration, some of immense sadness, but all incredible.”

This, then, is a series of incredible tales about the pre-hospital

This made me realise just how little the wider community knows about emergency departments emergency care provided by paramedics, the triaging process at the ED shop-front, and what happens within, unseen by those waiting, sometimes impatiently, outside.

It is about the young, not least women who give birth in ED apparently unaware that they were even pregnant, and the elderly who comprise the majority of presentations. We see how care is provided to road trauma and workplace accident patients, the drug overdoses, and those of any age or circumstance whose luck, or time, has simply run out.

Not surprisingly, end-of-life issues get due attention.

“Many GPs and specialists are reluctant to take the time to talk to their patients and families about realistic goals of treatment, and about when treatment should stop or be curtailed,” writes Dr Keith Edwards.

“This often puts emergency physicians in a difficult situation.

It’s frustrating when it is clear to

us that the patient is suffering and dying with an irreversible disease, and should be helped to die with dignity, but their GP or their specialist has said, ‘Go to the Emergency Department’.”

Amidst the trauma, the splitsecond clinical decisions and the frequent heartache - experienced by both family members and staff - there is humour aplenty, some of it uproarious.

“The bat phone rings. It’s 9 a.m. ‘We’re bringing in a sixtyyear-old Italian lady,’ says the voice on the other end. ‘Don’t know what’s wrong with her.

She’s really agitated. Might be a stroke.”

Dr Judkins - who, in another essay, becomes an ED patient himself - is on duty, and he directs the set up of IV, monitoring and CT… “It’s one of the challenges of the Emergency Department, the undifferentiated emergency…

We prepare ourselves, sharpen our wits and get the team ready for the crash and bang of an acute resuscitation.”

When the ambulance arrives, the patient is highly agitated, flailing and yelling that she’s dying. Staff are distressed, unsure of what to do, then mystified by the woman’s family whom they find laughing themselves silly.

Luca, the adult son, barely From page 10

expenditure in an open-ended demand scenario.

North Coast Primary Health Network’s Manager Strategic Development and Program Design, Sharyn White, said even though it was clear more work needed to be done, a lot of useful information had been obtained and that it was plain that practice nurse home visits were valued by patients.

“It was helpful to learn that the practice nurses deemed that a home visit was the best type of consultation for the patient in 97% of cases and that 90% of patients would

a publication of North Coast Primary Health Network

able to control himself, explains that he runs a pub where the previous night a band had left behind a batch of cookies.

“He knew Mama was cleaning up and told me to go and get the hash cookies before she found them. By the time I got there Mama was like this…It seems she had a few.”

An hour later, the patient, no longer on death’s door, was discharged.

“As they leave, Luca is supporting his mama, she reaches up and clips him over the head…and they all laugh again.”

Another good reason to buy a copy of this collection of doctors’ stories from the front line is that royalties go to support the work of the ACEM Foundation. have suffered if they’d had to attend the practice. These results underline the value of the Patient Centred Medical Home model.

“And it was useful to clarify that the main reasons given for the risk of patient suffering were frailty, mobility problems, or because the patient was under palliative care.

“The study also told us that there was inconsistent access to home nursing services across the region, a lack of clarity around the provision of these services and gaps in timing and accessibility to these services,” Sharyn added.

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Medicare freeze icing up health system

Dr Frank Jones

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ustralia’s two leading rural doctor organisations have urged the Federal Government to immediately end the indexation freeze on Medicare rebates.

The Rural Doctors Association of Australia (RDAA) and Australian College of Rural and Remote Medicine (ACRRM) warn that the freeze is hurting rural patients and ‘icing up’ the already fragile rural health care system.

They say it’s simply shifting the cost of health care onto patients and in many rural areas, patients can’t afford it.

“It is staggering to consider

that the Federal Government has just pumped an additional $3 billion into the pharmacy sector through the Sixth Community Pharmacy Agreement and is delivering a total of $18.7 billion to the pharmacy sector over the next five years.

“Yet it seems happy to continue to erode the viability of rural general practice and hurt already struggling rural patients by rejecting any calls to end the freeze on Medicare indexation,” said Prof Dennis Pashen, RDAA President.

“When you factor in consecutive CPI increases, through the freeze, the government is continuing to make a direct cut in the Medicare rebate for rural patients, many of whom are struggling financially,” he added.

He said that many rural patients with chronic health conditions have no option but to miss important health checks that could keep them out of hospital or to front up to the local hospital after hours to see a doctor.

Immunisation fears: parents’ survey

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niversity of Queensland researchers are hoping to get to the pointy end of parents’ fears about childhood vaccinations by conducting an Australia-wide survey.

A team from UQ is asking parents to participate in the survey of attitudes towards vaccination in the first nation-wide research into the issue for almost two decades.

Lead researcher Dr Cassandra Dittman said little was known about the attitudes of the current generation of Australian parents.

“If we know how parents form 36

their opinions, we can start to look at ways to have respectful and open discussions with them about vaccine safety and effectiveness, if that is what is required,’’ Dr Dittman said.

She said many parents were probably not vehemently opposed or strongly in favour of vaccines but would fit under the category of being “vaccine hesitant’’.

“These are parents who might express hesitancy by delaying vaccines, refusing some vaccines but accepting others, or by vaccinating their child but still feeling concerned or uncertain

New benzos prescribing guide

T

he Royal Australian College of General Practitioners (RACGP) has put together a new guide on prescribing benzodiazepines, focusing on patient-centred care, accountable prescribing and harm reduction.

Every year in Australia nearly seven million prescriptions for benzodiazepines are issued, with Valium and temazepam among the most common.

RACGP President Dr Frank R Jones said although benzodiazepines had been associated with both benefits and harms for patients, their use had led to growing concern about the harms associated with both their authorised and unauthorised use.

“There is significant debate in the medical community about the appropriate role and use of these drugs and this has been exacerbated by a lack of clinical guidelines in the area. The RACGP’s new guide Prescribing drugs of dependence in general practice,

about the fact that they had done so,” she said.

“As a researcher, I know and understand that vaccines work and are safe.

“But as a parent of a toddler, when I come across the latest emotive story about the risks or side-effects of vaccinations, my natural inclination, like any

a publication of North Coast Primary Health Network

Part B: Benzodiazepines is the first in Australia to comprehensively address these issues.

“Prescription of benzodiazepines should be based on a comprehensive medical assessment, a diagnosis, an examination of risks and benefits and a management plan.

“It is also important for patients to understand that medication is only part of the answer to managing complex mental health issues and nondrug therapies should also be explored,” Dr Jones added.

The guide explains that benzodiazepines should not be the first line of treatment and are generally regarded as a short-term therapeutic option. Long-term use, beyond four weeks, should be uncommon, made with caution and based on thoughtful consideration of the likely risks and benefits, accompanied with continued monitoring.

View the guide here: www. racgp.org.au/your-practice/ guidelines/drugs-ofdependence-b

parent, is to worry about ‘what if this happened to my child’?

“It’s these kinds of attitudes that we want to properly investigate.”

Parents of children aged five years and under can participate in the survey here: https://exp.psy.uq.edu.au/vax healthspeak Spring 2015

Fun and value in hidden labels

D

o you love wine, dear reader? I do. I actually love all facets of it, from the vine’s terroir and the viticulturist’s role in the vineyard to the winemaker’s attentions in the cellar. But one part of the wine experience which cannot be ignored is that for almost everyone (unless you are the winemaker) it is a marketable commodity.

This brings into focus how much it costs to make, the time it takes to mature in barrel and marketing and tax imposts. Paul Keating infamously brought forward the tax on wine from the point of sale to the point of bottling and this had the hopefully unforeseen effect of causing many very old vines to be pulled up. The tragedy of this played out in the Hunter with the loss of the legendary grapes used for Lindeman’s Hunter River Burgundy over many decades, and many other parts of Australia lost ancient vines which produced glorious wine.

I have been buying wine now for many years, from many retail outlets and from the cellar door.

Remembering this column is not indebted to anyone in the wine trade, I would like to give you my view on how best to aid winemakers, negotiants and yourselves alike, and hopefully keep the money in this country.

I am always a little concerned whenever a wine company lists on the stock exchange, as it will serve two gods, the need to put money back into the operation and the need to provide a shareholder profit. I have therefore always supported the First Families of Wine group, as family comes first and last. Similarly, I Spring 2015 healthspeak

wine Chris Ingall am happy to support family-run wine retail businesses.

The major food chains dominate around three quarters of the Australian wine retail market and offer good value with their loss-leaders, though it is difficult to know whether that value extends through the store. They have the size to offer a good, broad selection of wines from around the world, though do not generally advertise

The Wine Society is a Cooperative of Australian consumers, run

by Australians for Australians

Wine Society label. These are good wines and reasonably priced, though as they are not sold through other outlets it is difficult to know the exact valuefor-money they represent.

So what to do? I think the best value-for-money wines are found under Kemenys Hidden Labels. So what is this about, you say? Well, some clever person at Kemenys thought of a way where wine could be sold for about half its retail price under a ‘hidden’ label, where the winemaker’s name can be found in tiny print. This helps the winemaker sell his wine without devaluing his brand and helps the consumer in terms of price. It is easy to compare the hidden label price to the retail price (once you have discovered the winemaker’s name) and so you have a direct comparison available. Kemenys is a family owned Sydney business, and so this concept ticks all my boxes for buying exceptionally good wine at a very reasonable price.

Recently they had the Gemtree

Wine Tip Ever wondered how a marinade works? Well, it uses the same molecules found in wine to achieve a similar effect. Take lime and lemon juices (think riesling and semillon) and seafood for example. It is the citrus which causes protein breakdown, to partially digest the protein fibres. Pineapple and kiwifruit (think sauvignon blanc) have enzymes which act similarly. Tannins found mainly in red wine also have digestive properties, so wine marinates with every sip!

Cellar Tip

d

any direct collaboration with winemakers for anyone’s mutual benefit. Most of the web-based providers, such as Majestic Wines, are based overseas and their profits may well run in the same direction. In contrast, The Wine Society is a Cooperative of Australian consumers, run by Australians for Australians. They frequently negotiate directly with winemakers to produce excellent wines sold under the

Obsidian shiraz, normally $60$70 a bottle, selling for just $19 and while this was unusually generous, the discount is generally around 50%. I am drinking a wonderful Tasmanian pinot noir and a Sancerre-like sauvignon blanc from the Marlborough region both for around $15 a bottle, though both exhibit $30 quality. I could tell you who has made them but that would spoil your fun.

a publication of North Coast Primary Health Network

Remember, there are no great old wines, only great old bottles (though this is less true under Stelvin closure). If you want to see how your wines are going, inspect them regularly to check there is no ullage, or loss of wine from the bottle.

Looking through the neck of the bottle at the colour can be helpful, as brown is always bad. You can cellar your Stelvinclosed bottles upright and if you keep them in their box you can be assured of a longer life, though you do lose something cosmetically.

37

An Australian Abroad with Alex Lewers

Bulgaria and Romania

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s I swam around in the Mediterranean Sea, basking in the sunlight of southern Turkey, gazing back at the snow-covered peaks in the distance, it’s fair to say I had some fairly romantic ideas about seeing snow for the first time.

Setting forth from Turkey, we made our way towards the Bulgarian ski resort town of Bansko, ready for our snow adventures to begin. We now know that early season Bansko isn’t the greatest spot for beginners to learn the art of falling over, or as others call it snowboarding.

Needless to say, it didn’t take long for the images of me gliding care-free down the ski fields and having slow-motion snow fights to dissipate and be replaced by a harsh reality.

Snow is wet, very cold and hurts like hell when you have the snowboarding prowess of a drunk giraffe on ice skates.

At one point, such was my expertise on the slopes, that a young kid began mocking me mid-way through my run. I think he took comfort in the fact that had I wanted to, I was never going to be able to catch him.

After six days of snowboarding, I escaped Bansko with a right gluteal that Beyonce would be jealous of, scratches and a bleeding nose from using my face as an airbag, and a new found appreciation of gravity. Thankfully, however, I managed to escape with all bones intact.

From Bulgaria, we travelled north into Romania where we truly discovered what it felt like to be cold. On New Year’s Eve, we arrived in the Transylvanian town of Brasov with no real plans for celebrating the New Year.

By this point, everything was covered in a white blanket of snow, the hotel pool had ice thick enough to skate on, and it was almost impossible to stay outside longer than an hour at a time.

After thawing out in our room, we got a knock on the door from some other guests, who invited us to spend New Year’s Eve with them.

With temperatures reaching -17°C, I emptied the contents of my backpack onto myself in preparation and stepped outside, only to find our new friends casually cooking a BBQ in the snow.

In a naively Australian way, I had bought the finest and cheapest Bulgarian beer to enjoy for the night, much to the amusement of our hosts. It wasn’t until my beer turned Spring 2015 healthspeak

Above: New Years Eve in Brasov, Romania many families fill the streets and mingle around the famous Christmas Markets Left: Looking out over the slopes in Bansko Bulgaria Below: Soviet style architecture that is common in Bulgaria.

into a slushy shortly after that I began to understand why I was the only one drinking beer.

That night, we now regard as one of the highlights of our entire travels. We ate some of the best food of the whole trip (a blend of Ottoman, German and Hungarian cuisine), swapped stories about our cultures, and got introduced to Palinka (a Bulgarian brandy that’s more aptly described as rocket fuel).

By the time midnight came, it had reached -27°C, although, it’s fair to say that by this point the Palinka had definitely warmed all our souls.

Our experience in Brasov was fairly typical of much of our time in Bulgaria and Romania. Perhaps it was because it was winter, or we just got lucky, but we found the people we met extremely friendly and welcoming.

The food was perfect hearty winter fare, and

the pace of life provided a glimpse of what life in Europe might have felt like 20 years ago.

While it may not have the glamour of Paris or the energy of Barcelona, there’s an old-worldness to Bulgaria and Romania that is instantly comfortable and friendly. It’s a region steeped in history and tradition and one that draws you in and leaves you yearning to return.

a publication of North Coast Primary Health Network

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From page 22

worthwhile. To work directly with these people who have suffered so much and to help them feel a moment of feeling good about themselves is just wonderful.

“After he spoke everyone clapped and I asked this guy ‘when was the last time anyone applauded you?’ and he said he’d never been applauded for anything ever in his life. He’s a guy in his 70s. That moment was nice,” said Hilton with a smile.

In Chicago, Hilton had the privilege of working with young people who were inpatients at a mental health facility.

He said he fell in love with these young people as a result of their honesty and openness.

“For people who’ve had treatment in the mental health system which can be quite oppressive, it’s good for them to put a human face to the medical profession. And there was absolutely no bullshit about these young people.

Straight up they asked me ‘Mate, why are you doing this?’ ‘Why are you here?’. So I told them the story about my patient and her poem.”

Hilton says the writing exercises he offers are ‘simple, doable and really fun’. “Not only do people cry, but people laugh.”

Although he has plans to expand his writing cohorts, talking to Hilton you get the impression that he’s still amazed at where his writing workshops have taken him.

“Because everything I do comes purely from ideas out of my head. I have no formal training at all in teaching or writing. It’s all just ideas and I get to go to places like Harvard Medical School and Iowa University, Chicago and to Columbia University in New York where they have pioneered narrative medicine. To see my work well received by academics as well as ordinary folk gives me confidence, it’s good. Much better than prescribing anti-hypertensives or cholesterol lowering drugs,” he said.

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Bangalow – Rooms for Rent Dr Jane Reffell’s Women’s Health & Wellbeing practice in Bangalow, opposite the primary school, has rooms to rent – half or whole days available.

• Work alongside women’s health doctor and allied health practitioners…continence physio, psychologists, health coach, naturopath • Female & male clients • Pleasant rooms with electric bed, air con, suit either body work &/or consulting • Reception service available • Great opportunity to start/extend a business in Bangalow Please call 6687 2337 Tues to Thurs.

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Care Services

CARE

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SERVICES

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