HealthSpeak August 2018 by North Coast Primary Health Network

HealthSpeak CANCER ON THE NORTH COAST PRESCRIBING EXERCISE FOR CANCER PATIENTS From page 13

Nurses networking

Eating disorders

Link-me trial

20 on MNC

Health Workforce

24 Report

issue 22 • August 2018

THE VOICE FOR HEALTH PROFESSIONALS – FROM TWEED TO PORT MACQUARIE

Tackling cancer on the North Coast Head Office 106-108 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

editor Janet Grist

n this issue our feature looks at the topic of cancer. The region from Tweed to Port Macquarie has more cancer patients

Improving health is at the heart of all we do

Northern Rivers 2A Carrington Street Lismore 2480 Ph: 6627 3300 Email: enquiries@ncphn.org.au

acting ceo Sharyn White

Tweed Valley 145 Wharf St, Tweed Heads 2486 Phone: 07 5589 0500 Email: enquiries@ncphn.org.au

Health Speak Contacts Editor: Janet Grist Ph: 6618 5400 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 three 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 2018 North Coast Primary Health Network Magazine designed by Graphiti Design Studio www.gdstudio.com.au Printed by Quality Plus Printers

HealthSpeak is kindly supported by

than anywhere else in Australia. Fortunately we are lucky to have truly wonderful clinicians and researchers in our region working to improve outcomes for cancer patients. And the NCPHN Women’s Cancer Screening Collaborative that wound up in June had some real success in lifting our breast and cervical cancer screening rates.

t’s always good to remind ourselves of our purpose at NCPHN - better health for North Coast communities. It’s our residents who should always benefit from the work we do. In recent times, our organisation has been through a great deal of change, including shifts in funding arrangements and how we operate. But we must never lose sight of the fact that the needs of our community members are at the heart of all that we do. With 83% of Australians consulting a GP every year, it’s really important to foster strong general practice at the core of our patient-centred health system. And surrounding the patient are our wider health care neighbourhoods working together to ensure patients get the care they need. The total health expenditure in Australia each year is around $170 billion. Government health expenditure is just over $100 billion. Primary care health expenditure is $34.6 billion and NCPHN receives $30 million. It’s just a drop in the proverbial ocean and we need to use our funds wisely.

Our best approach is to work to be the glue that brings our health system together. Because even if we spent all of our funds on one area of health it wouldn’t really affect health outcomes. NCPHN receives funding from multiple funding streams. It’s really quite complicated. Each funding stream comes with strict

It’s vital that we can properly demonstrate we are meeting the measures required to create a more stable funding environment rules about how the money can be spent. So the art of successfully using funding as a Primary Health Network is to find the most creative way of applying the available funds within the guidelines. In this way we can be assured of obtaining the greatest benefit for our population. Commissioning isn’t just simply purchasing services. It’s a strategic process of working with the market to co-design, co-deliver and actively manage services that meet the needs of

Collaborations continue with radiotherapists, GPs and LHD and NCPHN staff working on new cancer HealthPathways to ensure that GPs have the best blueprint to best manage and care for their cancer patients. The feature starts on page 13. Look out for a new pilot involving exercise for cancer patients in our next issue. local communities. In addition to new funding guidelines, the Commonwealth Government has also given us a new performance framework. The new framework means that if we meet all the performance measures required we are guaranteed to have three years of funding. So we can give greater certainty to our health care providers about their ongoing funding as well. We understand that sometimes our providers of programs and services might get frustrated by the reporting process that is part of the performance framework. But it’s vital that we can properly demonstrate we are meeting the measures required to create a more stable funding environment. So while we operate in a very complex health care environment with competing demands from various stakeholders, the true art for us is to use the science of commissioning and the art of forging strong relationships to achieve the best outcomes for our community. As Acting CEO for the past six months, I have learned a great deal about navigating this complex environment. Fortunately I have been well supported by a knowledgeable and committed executive team and a passionate board. I am delighted to welcome Julie Sturgess, our new CEO, who will bring fresh and innovative thinking to the work that we do.

Cover: Byron Bay physiotherapist Dav Cohen working with patient Oxana. Photo: Edward Armytage.

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healthspeak August 2018

Recommendations from the National Indigenous Incarceration Conference 2018 clinical editor Andrew Binns

write as a GP who provides primary care to Indigenous people in an Aboriginal Controlled Health facility - Jullums Lismore Aboriginal Medical Service. One of our roles at Jullums is to provide health services to residents from a diversionary NSW Corrective Services facility called Balund-a. https://www. correctiveservices.justice.nsw.gov. au/Pages/CorrectiveServices/Community%20Corrections/offendermanagement-in-the-community/ balund-a_tabulam.aspx To gain more skill and understanding for this role I recently attended the National Indigenous Incarceration Conference (NIIC) held at Kingscliff. It was well attended with mainly Aboriginal and Torres Strait Islander (ATSI) speakers and delegates. For me it was a time to listen, learn and reflect. The figures on ATSI incarceration are alarming. To quote Labor Senator Patrick Dodson: “Indigenous people are more likely to come to the attention of the police, Indigenous people who come to the attention of police are more likely to be arrested and charged. Indigenous people who are charged are more likely to go to court. Indigenous people who appear in court are more likely to go to jail. Indigenous youth now comprise over 50% of juveniles in detention. The statistics speak for themselves and the cold fact remains an indictment on all of us.” Aboriginal prison statistics as detailed from: https://www.creativespirits.info/aboriginalculture/ law/aboriginal-prison-rates# Since 2004, the number of Aboriginal Australians in custody has increased by 88% compared to 28% for non-Aboriginal Australians. Australia is heading towards one in two of the prison population comprising Aboriginal prisoners by 2020. In 1992, the ratio was one in seven. August 2018 healthspeak

The Uluru Statement from the Heart

It seems the ‘tough on crime’ approach is failing

At the conclusion of the NIIC two recommendations were passed:

• A national review of out-ofhome care – acknowledging

the high rate of removal of ATSI children into out-ofhome care and the inherent links with juvenile justice and adult incarceration. The Commonwealth Government should establish a national inquiry into child protection laws and processes affecting ATSI children. This has been taken directly from Pathways to Justice – an inquiry into the incarceration rate of ATSI peoples published by the Australian Law Reforms Commission. The inquiry’s conclusion

was basically to promote justice reinvestment through redirection of resources from incarceration to prevention, rehabilitation and support to reduce reoffending and the long term cost of incarceration. It seems the ‘tough on crime’ approach is failing and building more jails is not the answer. Other countries such as in those in Scandinavia are getting much better results for much less cost than Australia. They also have an Indigenous community namely the Sami people.

• Raise the age of criminal responsibility from 10 to 15 years.

This is in line with the growing momentum for change and to bring us into line with other countries. The European average is 14. Other reasons cited are the protection of children’s rights, the limited ability of doli incapax (of 10-14 year olds not knowing their behaviour is wrong rather than

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just being mischievous) and issues of mental illness and cognitive impairment. A low age of criminal responsibility adversely affects Indigenous children who comprise the majority of children under 14 years who come before youth courts and are sentenced to detention or community based sanction. Finally, the NIIC concluded with a strong and emotional endorsement of the Uluru Statement from the Heart. https://www. referendumcouncil.org.au/sites/default/files/2017-05/Uluru_Statement_From_The_Heart_0.PDF This has also been endorsed by the AMA who lodged a submission to the Joint Select Committee on Constitutional Recognition. RACGP also recently endorsed the Uluru statement. The Uluru statement from the Heart has three main calls: to have a First Nations voice enshrined in the Australian Constitution; Makarrata which means 'bring the community together after a struggle'; and truth telling of the sixty millennia history of Australia. There are many health reasons alone why this statement is important. An article on Croakey website stated: “Paying attention to the social determinants of health is particularly important if we are to close the health and life expectancy gap between Indigenous and non-Indigenous Australians. In particular, racism, social exclusion, disempowerment and intergenerational trauma have been identified as important factors that need to be addressed before we will see real improvements in the lives and health of ATSI people.” They put five reasons forward why The Uluru Statement from

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What’s going on with the Nurse Network meetings?

CPHN’s Nurse Network Meetings return in August with the topic ‘Supporting the Older Patient’ in primary health care. This topic was chosen in response to feedback from local nurses about the need for further education on 75+ health assessments and My Aged Care. The theme is also relevant when considering the high number of avoidable hospital presentations in our area with the elderly tending to have escalating problems when they become sick or experience a fall at home. The goal is to promote health, mobility and independence for older folks. The Nurse Network Meetings were proposed back in 2015 to support primary health care nurses provide holistic patient care. Data showed that there were challenges for nurses who often felt isolated, with a shortage of professional development opportunities, and lack of peer support. Meetings are held in Kingscliff, Alstonville, Coffs Harbour and Port Macquarie.

up education related to meeting topics. It’s a private group page, so nurses need to email: lets. talk@ncphn.org.au to be invited to join. Post Grad Certificate

A great way to learn: Nurses Network Meeting on Wound Care at Kingscliff Beach and Bowls Club.

The face to face meetings started last year to help enhance the level of health care provided by primary care nurses. The latest meeting with the topic of Wound Care attracted a record number of 250 attendees across the footprint. Local nurses are keen to engage with the relevant topics and meetings format. Written feedback includes: ‘Great meeting, very informative,’ ‘Thank you for giving nurses the time to learn and

improve knowledge’, and ‘The chance to network is invaluable’. Online platform

Following the popularity of the Nurse Network meetings, a free online platform has been set up for primary care nurses. The Let’s Talk – Nurse Network Group is a tool to stay up to date with local events, discuss topics with peers and explore online CPD education. It’s also a means to access resources and follow-

NCPHN has also been working with Southern Cross University to develop a Post Graduate Certificate in Primary Health Care Nursing. The course is scheduled to start in October and NCPHN is subsidising five scholarships of 80% cost for nursing working in primary health care across the NCPHN footprint. Contact kcrossing@ ncphn.org.au or visit: ncphn.org. au/nurses for more information. Upcoming Meetings Tuesday August 28 at Kingscliff Beach and Bowls Club Thursday August 30 at Alstonville, House with No Steps Cafe Tuesday September 4 at Coffs Harbour, Opal Cove Resort Wed September 5 at Port Macquarie’s Town Green Inn

Specialist head and neck cancer care for regional patients When 76-year-old Elaine Madden went to her dentist about her bleeding gums, she wasn’t expecting a cancer diagnosis. A biopsy confirmed squamous cell carcinoma on the side of the tongue. Because Elaine had limited lung function, she was considered a high-risk candidate for surgery and was referred to head and neck surgeon at Chris O’Brien Lifehouse Associate Professor Carsten Palme. The head and neck service at Chris O’Brien Lifehouse cancer hospital sees the largest numbers of complex head and neck patients in New South Wales. A/Prof Palme says, “Having a concentration of cancer experts enables us to treat the most challenging and difficult cancers.” Luckily for Elaine and other regional patients, the Chris O’Brien Lifehouse head and neck service runs a follow up clinic in Port Macquarie where she can see A/Prof Palme once a month. She says, “If people can receive a diagnosis and follow up treatment in Port Macquarie

Professor Carsten Palme

and not have to travel to Sydney, I feel like half their battle has been won.” “Not having to take the long road trip each month means the world! I’m fortunate that my husband can still drive and I have people in Sydney I can stay with, but for most elderly people it wouldn’t be so easy and they wouldn’t be able to afford the trips to Sydney.” A/Prof Palme says, “The aim of our regional clinics is to give patients with head and neck cancer to prompt access to expert care and treatment by a multidisciplinary team.”

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Head and neck cancer is incredibly complex and diverse and includes more than 10 different types of cancer. There is a high concentration of vital nerves and vessels in the head and neck region, meaning that surgery is often complicated and challenging. Treatment can affect speech and swallowing, and the lasting traces are very visible compared to other types of cancer. “After I perform surgery and the completion of treatment, I personally follow up my patients for a period of up to five years. For regional patients, that can mean a lot of long trips.” “Many types of head and neck cancer have a good prognosis if detected early. Patients will come to me with a problem like persistent sore throat, change in voice or a neck lump. Our aim is to provide wider screening across the state so we can catch these cancers early resulting in better chance of survival.”

healthspeak August 2018

Community inspires innovation in pilot program for Indigenous clients

pilot compassion-focused therapy program for Aboriginal clients funded by NCPHN was transformed by turning to art to work successfully with clients. Compassionfocused therapy (CFT) is a recently developed evidence-based therapy, particularly focused on addressing high levels of shame and self-criticism. Often such people have backgrounds associated with experiences of trauma and hardship. Professor James Bennett- Levy and Aboriginal clinical psychologist Natalie Roxburgh ran the pilot program and James explained why compassion-based therapy was chosen to work with Aboriginal clients. “Experiences of intergenerational trauma, dispossession, hardship and high levels of current stress may often be associated with high levels of self-criticism and shame. Shame is a word often used by our In-

digenous population and therapies like cognitive behavioural therapy tend to hit a brick wall when it comes to shame, because if you feel like you don’t deserve to feel better then there isn’t the motivation to follow through.” Late last year Natalie and James ran two groups – one at Bunjum Aboriginal Corporation in Ballina, and one at Namatjira Haven Drug & Alcohol Healing Centre at Alstonville. A standard CFT approach was used over six sessions with materials adapted – for instance using Aboriginal images and language. “But it became clear that a standard psychoeducational approach, relying predominantly on group discussion and experiential exercises, just didn’t cut it,” said James. Furthermore, the group discussions about compassion sometimes triggered participants’ emotions and memories of the occasions when they had

experienced a lack of compassion in their lives. Natalie and James realised they needed to take a different approach, and based on feedback from the Bunjum Women’s group decided to introduce artbased activities. They contacted communitybased Real ArtWorks, inducted them into the CFT approach and came up with an art-based CFT program. Real ArtWorks’

I’m a 68-year old Aboriginal man. I never did any art as a kid. I never thought about what it was like to feel happy. Today when I was making art I realised ‘I feel happy. This is what happy feels like. Workshop participant

Continued page 39

Income splitting for Medical Professionals By Michael Carlton CEO & Senior Adviser, PECUNIA Private Wealth Management The idea is to redirect income to a spouse or dependant with a lower income, to bring the taxable income down to a marginal tax rate lower than yours, typically 47%. However, caution is warranted as the Australian Taxation Office (ATO) conducts many audits in this area, especially among those who use it incorrectly to reduce the tax liabilities of the higher-income-earning spouse. There are two types of income you may be able to split: passive or active. Passive income is earned from investments such as shares or an investment property. The ATO considers splitting this income with your spouse as generally acceptable.

August 2018 healthspeak

Passive income splitting is achieved by holding investment assets through discretionary family trusts where income can be distributed to low-earning taxpayers, or in the name of low-earning taxpayers, or even a company, which is taxed at a flat 30% rate. Active income is income earned from your own exertion (e.g. your private fees). Splitting this type of income is subject to strict rules. Usually referred to

as Personal Services Income or PSI, it is defined as ordinary or statutory income gained mainly as a reward for the personal efforts and skills of an individual. The ATO takes a simple approach to their assessment of “mainly”. If the income you earn is more than 50% for your effort and skill, then you classify this income as PSI. Whether this income was earned as a sole trader, or via a trust or company structure is often irrelevant. The basic rule is that you cannot split the income that you earn from your own personal exertion. Hence, opportunities to direct income away from the medical professional and split it with other individuals or entities are very limited. Generally speaking, all income earned by you must be included in your individual income tax return.

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ADVERTORIAL

Where you run a private practice and employ multiple staff, or a GP or dentist clinic with other contractors, a greater opportunity for income splitting exists through the use of a service entity. This is a very complex area of taxation where expert advice is required, and unfortunately we still see many cases where doctors and dentists have received incorrect tax advice.

Important information and disclaimer This publication has been prepared by Michael Carlton of Carlton Family Trust ABN 51 283 954 577 t/a PECUNIA Private Wealth Management, Authorised Representatives of Arrow Securities Group Pty Ltd ABN 30 165 731 144 AFSL No: 448218. Mascar Holdings Pty Ltd (Corporate Trustee) Carlton Family Trust Registered Tax (Financial) Adviser 25869223. This advice is general in nature and readers should seek their own professional advice before making any financial decisions.

NCPHN commissions $18.2m in services & programs

n the year leading up to June 30 2018, North Coast Primary Health Network’s commissioning team worked hard to secure more than 200 contracts with community organisations and health care providers to deliver services and programs to the residents of the region. Commissioning enables the PHN to use Commonwealth provided funding to improve the health outcomes of its communities by investing intelligently to shape the health and community care system. NCPHN’s Chair Dr Tony Lembke acknowledged the work required to achieve this outcome in an email to staff. He said that the commissioning process was vital to ensuring that every member of our community could access the care they need to best manage their health. “We needed to ensure that we allocated resources in each town guided by the experience of local communities and clinicians, having assessed needs both locally and throughout our entire region. We worked with international evidence to ensure we delivered the best value. This is an undertaking that had not been previously attempted on this scale.” Commissioning is one of the key ways NCPHN works to achieve health system improvement and we’d like to let you in on what it is and how it works. What is commissioning?

Commissioning is a process of working with the local providers to design and fund health and community care interventions to improve the health system and deliver better consumer outcomes. Commissioning relies on robust relationships and established trust at the local level. NCPHN works with stakeholders to identify needs and co-design solutions. Commissioning is underpinned by all of NCPHN's work, including analysis and planning, support for GPs and other health6

Commissioning is a process of working with the local providers to design and fund health and community care interventions to improve the health system Upskilling for commissioning: a Project Management workshop.

more about the detail, this can be found in our commissioning manuals. They can be found here: ncphn.org.au/commissioning Register with NCPHN

If your organisation is interested in working with NCPHN as a commissioned service, please register via our tenders, quotes and expression of interest portal Tenderlink: www.tenderlink. com/ncphn/ Great ideas

NCPHN’s Commissioning process

care providers and purchasing health and community care interventions. How it works

Commissioning is an on-going cyclical process. Needs are assessed through a combination of data analysis and consultation with clinicians and community members, carers or people with lived experience. Solutions are designed in partnership with stakeholders. When a new service is required, transparent processes are used to identify service providers

to implement these solutions. NCPHN uses Tenderlink when seeking proposals from providers. This ensures that the processes are fair and all competitors have equal access to information. These solutions are then monitored to ensure they are delivering what is required and evaluated to determine the outcomes achieved. This then informs further assessment and planning in the next phases of the commissioning cycle. Manuals

For those who want to know

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Requests for funding which fall outside the NCPHN formal commissioning approaches to market are known as unsolicited proposals. NCPHN accepts great ideas for innovative service delivery solutions where the proposal is uniquely placed to provide a value-for-money solution. These great ideas will be assessed twice a year as part of NCPHN planning processes. For more details about how these will be assessed, please visit: ncphn.org.au/tenders Proposals should be submitted online via our unsolicited proposals form available at the same location. You can also contact our commissioning team on this web page for assistance. To find out more about NCPHN’s commissioned services and programs, go to: https://ncphn. org.au/commissioned-services

healthspeak August 2018

Healthy Towns Workshops discuss identified issues

ommunity members, service providers and health professionals came together in six North Coast towns, during May and June to discuss health and wellbeing. North Coast Primary Health Network (NCPHN) hosted community workshops in each of the six towns selected to be part of the Healthy Towns program - Evans Head, Maclean, Woolgoolga, Casino, Lake Cathie and South West Rocks. The workshops followed extensive consultation over the past six months. Healthy Towns’ team members met with communities to find out about health and wellbeing issues, access to services and ideas for promoting wellbeing. Over 2500 community members participated in a survey across the six towns and about 150 face to face consultations were undertaken. An average of 50 participants attended workshops in each community. Participants were presented with the consultation outcomes and worked in small groups to brainstorm strategies to address identified needs. Topics discussed across all towns included ageing, transport, mental health, social isolation and diet and exercise. Feedback from communities was positive with one participant stating: “There should be more of this kind of community interaction. It made for an enjoyable and informative afternoon.” Here are a few of the ideas proposed in each town: Community connections

It’s now well understood that meaningful social connections are as important to good health outcomes as diet and exercise. The workshops therefore generated a broad range of ideas related to building community connections. Suggestions included wellbeing events, intergenerational activities, exercise groups, volunteer days and community spaces for people to gather. August 2018 healthspeak

Bringing people & services together

Ideas for people and services together were raised in each town. Local service information days, volunteer events, interagency forums and community information directories were some of the ideas in this space. Addressing service gaps

Rural Australians have poorer access to health services than their urban counterparts. Workshop participants generated creative ideas to address service gaps in each town. Suggestions included shared rosters for local medical services, telehealth, outreach and commissioning new services. Healthy Towns now enters an exciting new phase. NCPHN will work with partners at the Mid North Coast and Northern NSW Local Health Districts. Aboriginal Medical Services, communities and local service

From left: Matthew Eldridge, NUM, Kempsey Community Health; Judy O’Mara, Rural Adversity Mental Health Coordinator, Centre for Rural and Remote Health; and Larah Kennedy, Senior Project Officer, NCPHN at the South West Rocks workshop.

providers to advance selected initiatives. Working groups in each town will collaboratively design local projects.

New home for Art on Bundjalung The Art on Bundjalung Country project, managed up till now by NCPHN, is continuing into its second year with Arts Northern Rivers now running the project. The project is an arts and health initiative designed to enhance social and cultural connectedness improving health and wellbeing through the creation of artworks by the North Coast’s Indigenous population. In addition to

Sarah Bolt

developing new skills, the project has expanded to assist artists in marketing and selling their work. The decision to commission Arts Northern Rivers to take over the

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The Healthy Towns team can’t wait to see some great outcomes in the second half of the year. ncphn.org.au/healthy-towns

project was made by the Art on Bundjalung Country Project Steering Committee. Arts Northern Rivers was nominated as the most appropriate organisation to take on the project and Arts Northern Rivers CEO Peter Woods was delighted to accept. The project’s manager Sarah Bolt continues to head the project and is now based at Lismore Regional Gallery. Lismore Regional Gallery Director Brett Adlington is a big supporter of the Art on Bundjalung Country Project. Stay tuned for exciting developments.

Eating Disorders: help is on its way... By Dr Brenda Rattray GP and Clinical Lead, HealthPathways

ating disorders can affect girls and boys, women and men, and people from all backgrounds. But due to stigma or misperceptions, some people may still not get the help they need. Eating disorders are not a silly desire to be thin, a figment of one's imagination, or a failing. Eating disorders are serious, even life-threatening medical illnesses with biological and psychological causes. They are treatable and recovery is possible. As a general practitioner, I have sometimes felt alone and overwhelmed trying to manage some of these really ill patients. In the past it has been difficult to access specialist advice on management as well as services. The great news is that the state government has identified Eating Disorders as a priority by developing the NSW Health Service Plan for People with Eating Disorders (2013-2018). This has led to the establishment of an Eating Disorder Coordinator

I have sometimes felt alone and overwhelmed trying to manage some of these really ill patients in every LHD to lead service development, develop local referral pathways and provide clinical consultation to support primary care clinicians.

Eating disorders therapy trial

Hundreds of people with eating disorders will get access to up to 50 psychotherapy sessions under a pilot study on Queensland's Sunshine Coast. The 18-month trial will tailor multidisciplinary therapy services to each patient, based on individual

needs. The Sunshine Coast has a higher than average incidence of eating disorders. Federal Health Minister Greg Hunt said local GPs would be trained to identify, assess and treat eating disorders. A total of $3.2 million will be spent on the trial as well as educating GPs across Queensland.

In consultation with our MNCLHD and NNSWLHD Eating Disorders Coordinators, the HealthPathways team recently published a series of pathways to assist practitioners. The pathway provides useful information on assessment, indicators for admission, management advice and much needed referral information for both adults and children. The pathways also provide the links to our local Eating Disorder Coordinators and a dedicated Eating Disorders Counselling and Support page where clinicians and patients themselves can access service, counselling

support and online resources. Our new HealthPathways include: Eating Disorders in Adults Eating Disorders in Children and Adolescents Eating Disorder Assessment for Adults Eating Disorder Assessment for Children and Adolescents Eating Disorder Advice Eating Disorder Counselling and Support www.manc.healthpathways.org. au Username: manchealth Password: conn3ct3d Videoconference session On September 5, a one-hour videoconference will be available on Treating Young People with Eating Disorders. The topic is: The use of Medication during Disorder Treatment presented by Dr Maugan Rimmer, consultant psychiatrist. The session will run from 12.30 to 1.30pm. This session is streamed from Westmead Children’s Hospital and if you want to join, please RSVP via email to Ute.Morris@ health.nsw.gov.au

Pharmacy DAA program expanded

n extra 70,000 patients of community pharmacies will benefit under the expansion of a Federal Government medication adherence program. The Government will provide funding for an extension of the Dose Administration Aid (DAA) program to help more patients manage their medicines

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and avoid medication misadventure and hospitalisation. The National President of the Pharmacy Guild, George Tambassis, welcomed the Government’s commitment to the program. “This is a significant and wise investment in keeping people out of hospital and delivering the best possible health outcomes,” he said. Under the Pharmacy Compact between the Government and the Pharmacy Guild of Australia, since 1 July 2017 the Government has provided $6 per patient to community pharmacies that provide a weekly DAA to patients who meet the eligibility criteria. healthspeak August 2018

The Buttery’s b.well program: client success story T

he Buttery’s b.well program, funded through North Coast Primary Health Network, operates across the Northern Rivers Region. b.well provides support within the community for people with mental health issues who are concerned about the impact of their use of drugs and alcohol on their well-being. The philosophy of the b.well team is to instil hope and understanding and to create a sense of belonging for people who identify as having mental health and substance abuse issues. b.well is free and confidential and people of all ages can selfrefer to the program. Through b.well people can access a range of services including: Psycho education Peer support groups Individual support Activities programs Life skills programs Early intervention Living healthily programs Now I believe in myself: Jonathan’s story

Now 22, Jonathan is a former b.well client who has started a new life in Melbourne. Recently he reported that he is happy, employed and has a new network of friends. By 21 Jonathan had overcome more challenges than most young men his age. After a childhood dealing with a host of family issues, at 16 he broke his back in a motor bike accident. “I thought I’d never walk again and have a life of pain.” After major surgery and rehabilitation, he managed to walk again. However, after the accident Jonathan suffered extreme anxiety. “I was so anxious I couldn’t even go into a supermarket. I was unsteady around people and August 2018 healthspeak

The entrance to the Buttery

Jonathan is now happy, employed and enjoying a new friends' circle.

depressed.” It was an unsettling time for him. Although he’d never taken illicit drugs, Jonathan started going to doofs and taking Ecstasy and MDMA. Expelled from school, he started delivering pizzas until the pizza shop went bankrupt. Unemployed and aimless he smoked cannabis daily. “I didn’t want to be lonely so I hung out with people smoking pot all day.” Jonathan’s life changed dramatically after testing positive for cannabis in a police drug test. He lost his licence and he said his anxiety became even worse. Jonathan started taking part on The Buttery’s b.well program for people who may have substance misuse and mental health issues. His counsellor Amanda Hewitt has the lived experience of recovery from addiction and of managing her own mental health issues. “I’d been to a psychologist before and I didn’t relate to him at all with his nice clothes and the way he talked. I came away from

I’d been to a psychologist before and I didn’t relate to him at all with his nice clothes and the way he talked the sessions feeling worse. With Amanda it was different. She really understands what it’s like to feel extremely anxious and to have issues with drugs.” “Amanda has taught me how to understand the triggers for anxiety and how to practise mindfulness and other techniques. I feel 100% more comfortable in my own body.” “Amanda taught me how to start my day. She suggested I buy some joggers and start walking for regular exercise. She told me to stop thinking about my troubles, get a routine, go out for

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a walk and eat healthily.” “Words can’t describe how good she’s been for me. She makes me believe in myself and gives me practical advice on how to lead a better life.” Jonathan now has a job he likes and is becoming physically fit. He’s optimistic about his future and is considering further study to become a counsellor so he can help other people. b.well Coordinator Frances Pidcock told HealthSpeak that her team involves people from different walks of life. “We have 50% lived experience, we have a peer worker and two lived experience counsellors, a great skills mix and we also have some great volunteers.” b.well activities include walking groups, drumming groups, weaving and art therapy. b.well has also set up a group for 14 to 16 year old girls at Nimbin Central School. Two workers visit weekly and are available for young people who want to talk about early intervention. “The transition to womanhood group has been a big success. The girls are encouraged to talk about social media, sexuality, mental health and addiction in a conversational style with support from a welfare worker and a psychologist. It’s going so well the girls don’t want it to end.” For details of current groups contact bwell@buttery.org.au or phone 6687 1658.

My Health Record finds positive traction with consumers

s a father of two, Scott Spies from Coffs Harbour has his hands full at the best of times. Fortunately for Scott, My Health Record makes life a lot easier when it comes to visiting the doctor. As a user for some time now, Scott says that having a My Health Record makes appointments a lot easier. “It makes filling out paperwork easy and I’m able to keep track of the children’s medical records even though they see more than one doctor”, Scott says. Scott’s positivity towards My Health Record was echoed at recent community events across the region. “The ability to add your Advance Care Plan to My Health Record was especially popular amongst seniors I spoke to at the Tweed Heads Seniors Expo”,

Seniors finding out more at the Aged Care Symposium.

said North Coast Primary Health Network (NCPHN) Community Engagement Officer, Therese Gerber. “People like to know that they can have a voice in important medical decisions about them

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at a time when they are not able to speak for themselves”, said Therese. “Seeing positive sentiment when we engage with consumers is encouraging following some negative media sentiment after the opt-out period started in mid-July” says Amanda Wilkinson, NCPHN My Health Record Program Manager.

Scott’s positivity towards My Health Record was echoed at recent community events across the region

“In fact, the consumer sentiment gauge used at the North Coast Aged Cared Symposium in Ballina in July showed a high level of positive sentiment towards My Health Record”. “People feel a lot more at ease when they learn that they can set their own security features around who sees their record and what they see, and set up an alert for when anyone accesses their record”, said NCPHN Community Engagement Officer Emma Dykes. The benefits of My Health Record such as better connected care and instant access to health information during an emergency, will become more noticeable to consumers as the number and range of registered health providers increase. With public hospitals now uploading discharge summaries - and more than 90% of North Coast general practices and 85% of pharmacies registered - in coming months patients with My Health Records and their healthcare professionals will see more health information uploaded. The NCPHN team encourages consumers to use the My Health Record website – www. myhealthrecord.gov.au – or call the national helpline on 1800 723 471 for more information. They can also contact the NCPHN team on (02) 6618 5400 or enquiries@ncphn.org.au to request community information sessions.

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Measuring consumer sentiment in Ballina.

a publication of North Coast Primary Health Network

healthspeak August 2018

Coffs dentists rally to emergency call out service

hen the Emergency Department (ED) of Coffs Harbour hospital put out the call for assistance in managing dental emergencies in our region, nearly 30 community minded dentists were willing to help. The Emergency dental on-call Service pilot project commenced in July 2018 and will see dentists from Coffs Harbour and nearby areas volunteering their time to help medical colleagues to manage uncertain dental situations. The rostered service will provide a consulting dentist each weekend and a list of emergency dental service options. Oral conditions are the third-highest reason for acute preventable hospital admissions in Australia, accounting for more than 63,000 hospitalisations annually. Unfortunately, a lot of these presentations come through our Emergency Departments. This is not only clogging up our Emergency Departments and burdening emergency staff, but also oneoff emergency management is seldom the solution to a dental problem. Lack of definitive care and appropriate follow-up for dental conditions means that patients are more likely to make multiple ED visits with the same complaint. It is hoped that both definitive management and follow-up care will be enhanced through the voluntary dental emergency service, resulting in an overall improvement in the way dental emergencies are managed. Program organisers Dr Kate Amos and Kirsty Christensen expect the pilot to be wellreceived given that up to 4% of presentations to Emergency may be due to dental or oral health concerns. The program is the direct result of consultation through North Coast Primary Health Network between ED representatives and local dentists, providing a clear example August 2018 healthspeak

Ultimately, we would like to see fewer dental complaints reaching our ED colleagues

From left: Three dentists participating in the service: Dr Cecilia Mwanje, Dr Benjamin Mansell and Dr Cathy Do.

of how facilitating inter-professional conversations can lead to innovations that benefit the community. “It’s a great thing to see local dentists banding together and volunteering their own time to help their medical colleagues and the broader community,” said Dr Amos. “The aim is to enhance the ability of our local ED team to manage dental complaints and to provide improved follow up support. Ultimately, we would like to see fewer dental complaints reaching our ED colleagues. But for now, improving the processes that occur when a patient presents with a dental emergency is our priority.” Sharyn White, Acting CEO of North Coast Primary Health Network, said the pilot was a great example of how the PHN can facilitate local solutions to local problems. “This was a problem identified by the Coffs Clinical Council and then the members worked to broker a local solution. I love seeing these clinician-led initiatives and think we, as an organisation, need to continue to learn how to facilitate more of them”.

The pilot program will run for 12 months, with evaluation occurring throughout. If the service is successful, it may extend in scope in the future. The initiative is part of a

broader movement to improve access to dental care in our region and to upskill medical and allied health professionals in this area. HealthPathways content is being updated to include useful oral HealthPathways locally and to reflect the link between poor oral health and other serious illnesses including diabetes, cardiovascular disease, stroke, respiratory illness, and obesity – all of which place a significant burden on the health system.

Patients want GPs to use technology

According to MedicalDirector’s Patient Engagement Survey 2018, conducted with online appointment and ehealth platform HotDoc, Australians want doctors to adopt tech solutions to improve convenience, patient empowerment and care outcomes. A survey of more than 2,000 patients found that 70 per cent want health care providers to improve their use of digital tools, mobile technology and the internet.

a publication of North Coast Primary Health Network

Patients are particularly attracted to technologies that could help them better manage their appointments, communicate with their GPs and get test results. Patients also said they want continuity of care for better health outcomes. With most patients (80 per cent) visiting their doctor at least every six months, among respondents patient loyalty to GPs was high with 72 per cent of respondents consulting the same doctor for more than two years.

Emergency protocols project wins Quality Award

rotocols” project team as overall winner at the 2018 NNSWLHD Quality Awards from NNSWLHD Board Member Carolyn Byrne. A project set to revolutionise emergency departments across NSW was the overall winner at the 2018 Northern NSW Local Health District (NNSWLHD) Quality Awards, held in Tweed Heads on 15 June. The Emergency Protocols project team was led by Maclean District Hospital’s Dr DeanRobertson and Lismore Base Hospital Emergency Physician Dr Charlotte Hall, along with Dr Sabrina Pit, Dr Margaret Rolfe, Sharene Pascoe, Dr Megan Passey, Dr John Mackenzie and Dr Lindsay Murray. Through collaborative work by local practitioners and researchers from the University Centre for Rural Health the project team developed and tested a set of quick reference manuals for use in emergency departments modelled on those

“Congratulations to the whole team for putting together such a fantastic project.” More information about the project and copies of the reference guidesis available at www.emergencyprotocols.org.au North Coast Primary Health Network is a sponsor of the Awards.

Dr Dean Robertson and Dr Charlotte Hall accept the award on behalf of the Emergency Protocols Project Team.

The outstanding results in the trials of the Emergency Protocols were very promising used in the aviation industry. Running controlled trials with

21 teams of doctors and nurses across 84 crisis scenarios, the team found that using the emergency protocol manuals led to a 54 per cent reduction in critical errors in the emergency setting. “The outstanding results in the trials of the Emergency Protocols were very promising, and we’ve already started using them in our EDs across the district,” NNSWLHD Chief Executive Wayne Jones said.

New test reveals colour biomarkers of chronic pain

ustralian neuroscientist Professor Mark Hutchinson has developed an on the spot blood test that identifies chronic pain by colour “biomarkers”. Professor Hutchinson developed the world-first test and believes the breakthrough has the potential to revolutionise the diagnosis and treatment for the one in five Australians who suffer chronic pain. Professor Hutchinson told a meeting of the Australian and New Zealand College of Anaesthetists that the test would also benefit the diagnosis of pain in babies and dementia sufferers who are unable to communicate the extent or source of their pain. “This gives us a brand new 12

window into patients’ pain because we have created a new tool that not only allows for greater certainty of diagnosis but also can guide better drug treatment options,” he explained. Professor Hutchinson, who has played a leading role in the development of blood tests for chronic pain, is the Director of the Australian Research Council Centre of Excellence for Nanoscale BioPhotonics at the University of Adelaide. He believes the “painHS” test could be ready for broader use

by pain medicine physicians and GPs within 18 months as a cost effective test to determine the severity of chronic pain in patients with lower back pain, fibromyalgia, pelvic pain, cancer pain and migraine. He said the test could also be used in animals.

a publication of North Coast Primary Health Network

briefs

Rural antismoking campaign call The Rural Doctors Association of Australia believes it’s time that anti-smoking campaigns were targeted to rural areas where people continue to smoke at ‘alarming rates’. RDA President Dr Adam Coltzau said smoking was the single largest preventable cause of death and disease in Australia. “One in five people living in outer regional or remote areas smoke daily, which makes them about 1.7 times more likely to smoke that those in our major cities. “We want to see Governments across Australia tackle this issue and concentrate on reducing smoking rates in rural areas. The Minister for Indigenous Health, Ken Wyatt, has ensured continued funding for the Tackling Indigenous Smoking program and we commend his work in this area. “But currently there is no program aimed at reducing smoking rates in the broader rural and remote community. This should be addressed as a matter of urgency,” he said.

healthspeak August 2018

F E AT U R E

CANCER ON THE NORTH COAST A SNAPSHOT EARLIER THIS YEAR A REPORT BY THE AUSTRALIAN INSTITUTE OF HEALTH AND WELFARE (AIHW) REVEALED THE REGION FROM TWEED HEADS TO PORT MACQUARIE HAS MORE CANCER PATIENTS PER 100,000 PEOPLE THAN ANYWHERE ELSE IN AUSTRALIA.

The report showed that for every 100,000 people on the North Coast, 546 were diagnosed with some variation of cancer between 2009 and 2013 - well above the national average of 497 cases per 100,000 people. The data also revealed the North Coast had the highest rate of melanoma cases across Australia. Among other cancers, the North Coast has higher rates of colorectal and lung cancer rates than the rest of Australia, while leukaemia, lymphoma, cervical and pancreatic cancer rates are lower. The North Coast Cancer Institute tells us that the three most commonly treated cancers are breast, bowel and lung cancer.

working collaboratively with clinicians and health organisations to increase screening rates for breast and cervical cancer. Recent activities: Conducted the successful Women’s Cancer Screening Collaborative in 2017/18 The Collaborative included targeting specific patient populations and standardising coding to extract relevant data Publishing the Measuring for Improvement Guide to explain the process of how to improve screening rates In 2017, as part of the WCSC we held a Women’s Health Conference in Kingscliff and Port Macquarie to bring clinicians up to date with data and methods to prevent and detect cancer and provide the best care Developed extensive HealthPathways to help GPs ensure they provide the best preventive advice and care. We will be commencing a program to tackle Aboriginal cancer rates in 2018/19.

OTHER FACTORS The figures published by the AIHW do not of course, tell the whole story. The Clinical Director of the North Coast Cancer Institute Prof Tom Shakespeare is on the record as saying that h our region’s higher smoking rates are partially to blame. Smoking is known to be a cause of not just lung cancer, but head and neck, mouth cancer, throat cancer, stomach and even bladder cancer. Smoking is also thought to cause some skin cancers. And of lifestyle factors - obesity, lack of exercise, high alcohol consumption and high fat diets are problematic. TREATING CANCERS The good news is that North Coast residents have world-class treatment facilities at the Mid North Coast Cancer Institute and North Coast Cancer Institute. In this feature we speak to local experts about current treatments and supports and find out more about what NCPHN is doing collaboratively to increase screening rates and help clinicians provide the best possible cancer care.

POSSIBLE REASONS Incidence rates may be high due to more detection rather than more disease Mortality rates may be worse due to late detection or poorer care A population older than most parts of Australia with increased cancer screening WHAT NCPHN IS DOING North Coast Primary Health Network is

Cabarita Beach

H E A LT H S P E A K

AU G U ST 2018

WOMEN’S CANCER SCREENING COLLABORATIVE SAVES LIVES THE 2017/18 NORTH COAST PRIMARY HEALTH NETWORK’S WOMEN’S CANCER SCREENING COLLABORATIVE (WCSC) ENDED WITH SOME WELCOME INCREASES IN CANCER SCREENING PARTICIPATION RATES IN OUR REGION.

In 74% of participating practices breast screening participation rates improved due to the Collaborative In 68% of participating practices cervical screening participation rates improved due to the Collaborative

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In addition, participating practices reported some heartwarming results. These included: “In recent weeks we’ve had three women diagnosed with breast cancer after being actively recalled by our surgery for mammograms (as a result of our involvement in the Collaborative). …Now they are receiving treatment and have good prognoses. This made what we are doing so very worthwhile.” “We have had two patients picked up with early breast cancer from our screening who otherwise wouldn’t have been picked up.” “Due to our new reminder and follow up systems, an asymptomatic patient aged 67 who’d never had a mammogram presented to NSW BreastScreen after receiving reminders from our practice. She is now undergoing treatment for early detected breast cancers. In my 18 years as a practice manager this would have to be one of the most worthwhile, fulfilling programs I’ve had the pleasure of being involved in. This is clear evidence the WCSC can and will help save lives.” ABOUT THE WCSC The WCSC ran from January 2017 to June 2018 and was led by two Senior Project Officers – Sara Gloede who left in December 2017 to have a baby and Meg Baker who took over at this point. It was funded by a Cancer Institute NSW grant and by North Coast Primary Health Network. The WCSC’s main objective was to increase breast cancer and cervical cancer screening in the North Coast and Mid North Coast regions of NSW. It involved

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Dr Jo Adendorff

WE HAVE HAD TWO PATIENTS PICKED UP WITH EARLY BREAST CANCER FROM OUR SCREENING WHO OTHERWISE WOULDN’T HAVE BEEN PICKED UP partnerships between general practices, Aboriginal Medical Services, and stakeholders including NCPHN, Breastscreen NSW, Local Health Districts, and Cancer Institute NSW. AIM With regards to breast cancer, the WCSC aim was to increase the number of women aged 50 to 74 having regular mammograms, with a target of 70%. The state average for mammogram participation is 53.2%. On average the participation rate in the PHN footprint was 57.1%. Of particular concern were Aboriginal and Torres Strait Islander women, where participation rates are as low as 29%, and Culturally and Linguistically Diverse populations, with rates falling to 21% in one area. With regards to cervical cancer, the aim was to increase the number of women aged 50 to 74 having regular cervical cancer screening checks. Once again, concentrating on at risk populations. PROJECT The aim was to recruit 10 general practices but there was a high level of interest and 22 practices enrolled. They were divided into five clusters: Port Macqua-

rie, South West Rocks, Coffs Harbour, Lismore and Tweed. The cluster system allowed for local networks to be set up and relationships forged. Workshops and other activities were also able to deliver a tailored, local approach. The Collaborative piloted a two pronged approach: Understanding primary care infrastructure and data limitations, and working directly with clinicians to address these Exploring ways to improve access and equity to screening through health literacy informed by a consumer research project. Collaborative participants attended three workshops and a Women’s Health Conference. Dr Jo Adendorff, a GP at Tintenbar Medical Centre was the Clinical Lead for the WCSC. With a background in Family Planning, Jo runs a women’s health clinic at Tintenbar. Breast and cervical cancer are conditions she feels particularly strongly about. She also works at Bulgarr Ngaru Aboriginal Medical Corporation, running a women’s health clinic each month at Kyogle. Jo, who gave a presentation about the WCSC at the BreastScreen Australia Conference in Adelaide in April, spoke to HealthSpeak about the Collaborative. She said the first of the two-pronged approach was all about data. “First the practices came together and looked at ways to examine their data. Who are the women we are screening now and how are we recalling these women?” This approach allowed practices to identify the subset of women involved in screening and also identify those women who were under-screened or had never been screened. “When we looked at the predominant groups of under-screened women this triggered discussion about how we could better engage those women and offer them screening and give them better access to screening,” she explained. Work was also done on specific patient populations and how results were coded. Standardisation of coding was identified as key in extracting relevant data. The

work on data extraction was time-consuming but lessons learned have been distilled into shortcuts in the WCSC Measuring for Improvement Guide – a boon for practices wanting to use the process to improve screening rates. The work on data was supported by a series of three workshops held in each cluster.

“These officers would go out to practices and report back challenges practices were experiencing, such as limitations in current software. PHN Project managers would then approach the software developers and work with them to come up with the software needed to successfully mine the data. And the officers would communicate to and from the practice as changes were made to improve data collection and analysis,” said Jo. The second part of the Collaborative involved improving access and equity in screening programs. This included both health literacy and consumer research components. NCPHN health literacy specialist Taya Prescott supported practices in ensuring SMS reminder texts, recall letters and communication was written at an appropriate level. Discussion also came

The Collaborative increased breast screening rates in our region

I CAN’T STRESS ENOUGH HOW POSITIVE AN EXPERIENCE IT WAS WATCHING PEOPLE COME TOGETHER FROM DIFFERENT PRACTICES & BRAINSTORM IDEAS up with new ways to convey screening information such as specific awareness days, written prompts at reception desks, and take home packs. The final phase of the WCSC was the Consumer Research Project – qualitative research exploring personal, social and cultural barriers and enablers for women to screen. Five focus groups were held and results fed back to BreastScreen NSW. The final report can be found at: https://ncphn.org.au/wcsc/ Common barriers included Low personal priority to screen for women’s cancers Lack of time, transport & cost issues No reminder from GP Negative past experience of screening and little knowledge of screening Common enablers included Screening for early detection of cancer Reminders and prompts from GP Having a female GP Access to a women’s health centre Help with transport Community-based promotions and education OUTCOMES There are now strong, ongoing relationships between practices within each cluster as well as increased use of local contacts, supports and Pathways.

“I can’t stress enough how positive an experience it was watching people come together from different practices and brainstorm ideas. Because often in general practice we work to a degree in isolation. And to have people from organisations such as BreastScreen, the Primary Health Network, the Local Health Districts and the Cancer Institute coming together in workshops was really important in relationship building.” Jo said there was now a really fun culture of stealing ideas shamelessly from each other and measurable changes from the project: 74% of participating practices said their breast screening participation rates had improved 68% of participating practices said their cervical screening participation rates had improved 90% of participating practices have made changes to how they manage cancer screening results and reminders 94% of participating practices now have a recall and reminder system (72% prior to WCSC) 72% of practices have changed the way they educate and raise awareness about breast cancer screening

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WORKSHOPS AND OTHER SUPPORT The workshops involved presentations about clinical issues, screening processes, health literacy and information about quality improvement tools. “Probably the most important thing they did was facilitate group discussions, enabling people to get together to discuss challenges, ideas, and share information about things they were trialling that worked, and things that didn’t,” said Jo. The outcomes from the first two workshops informed the development of the consumer research phase. Other supports included: Two Women’s Health Conferences held in late 2017, involving 178 delegates and presentations from specialists, Clinical Nurse Consultants, Family Planning NSW, and IT Consultants Cancer Institute NSW provision of patient lists for each practice showing their patients’ most recent BreastScreen mammogram regular newsletters and a project website visits from NCPHN support officers to clinics

And of course for Jo a real highlight has been the practices whose efforts resulted in women who otherwise would not have been screened being diagnosed with early stage cancer and are now receiving treatment. RESOURCES The WCSC also led to the development of some great resources that are available here: https://ncphn.org.au/wcsc/

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COLLABORATIVE CANCER PROJECT BUILDS HEALTHPATHWAYS

CA N CE R O N T H E N O RT H COA ST

orthern NSW Local Health District, Mid North Coast Local Health District and North Coast Primary Health Network (NCPHN) have been working collaboratively to localise cancer pathways using the HealthPathways platform. Optimal cancer pathways have been published by Cancer Australia, and Cancer Institute NSW has provided grant funding for these to be localised across the state. The need for a lung cancer pathway was identified locally and work commenced to make it happen. In 2015 NNSWLHD was the regional pilot site to localise a lung cancer pathway in NSW. Since that time localised cancer pathways have been an ongoing project collaboration between the Mid North Coast and Northern NSW LHDs and NCPHN. In recent times, Northern NSW LHD radiation therapist Lisa Delaney has been leading the HealthPathways cancer project team. She has worked closely with Deputy Chief radiation therapist Stephen Manley, GPs Hilton Koppe and Kate Allen and HealthPathways Coordinator Kerrie Keyte to bring new cancer HealthPathways to fruition. Thanks also to the clinical editors and project officers whose work was important in developing the new pathways. PATHWAYS FUNDING The development of cancer HealthPathways are funded through grants from Cancer Institute NSW. And recently a grant to develop a bowel cancer HealthPathway was approved. In fact, Cancer Institute NSW has expressed their satisfaction in our HealthPathways’ team’s ability to deliver these outcomes for its communities. IMPORTANCE OF UPDATING While working on new pathways, the team has also revisited the 2015 lung cancer pathway to update it. Stephen told HealthSpeak that it was important to pause and look back at previously published HealthPathways. “There have been some amendments to language and style, we wanted to be consistent across all HealthPathways,” he explained.

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CANCER HEALTHPATHWAYS Find these at: https:// manc.healthpathways. org.au/ User name: manchealth Password: conn3ct3d Lung cancer Ovarian cancer Endometrial cancer Cervical cancer Psychosocial care in cancer Head & Neck cancer Breast cancer Ovarian cyst Breast cancer screening, breast symptoms & breast cancer management Bowel cancer screening Cervical cancer screening Colposcopy Head & Neck lumps Service/referral pages Genetics – linking to cancer syndromes

The revised Lung Cancer pathway contains an important change. Best practice now dictates that the first referral should be to a respiratory physician where possible, who then presents the case to a multidisciplinary team of specialists. A new cancer HealthPathway that will make the life of a GP a lot easier is the Psychosocial Care in Cancer Pathway. It provides a clear pathway to support patients both during and after their cancer treatment. Stephen said the Psychosocial Care in Cancer Pathway was like discovering an opal and came about as part of funding for an ovarian cancer pathway that was scoped to begin at referral, move onto diagnosis and proceed all the way to follow up. “It was quite amazing how little even those in the know knew about the different activities and resources available. So we decided to make this pathway a freestanding one relating to all cancers,

Chief radiation therapist Stephen Manley and Northern NSW LHD radiation therapist Lisa Delaney

with GPs as the primary audience.” The Psychosocial Care in Cancer pathway will also be a boon to consumers as it centralises information about support services and resources. SURVIVORSHIP A spinoff from this pathway was that the Cancer Council NSW’s Enriching Survivorship Program was identified as a valuable program for the North Coast. “But the program was predominantly available in city sites and there was no face to face availability regionally. We were able to negotiate with Cancer Council NSW to have a one-off survivorship program delivered locally and the first 8-week program started in Lismore in May. We’ll evaluate it and hope to provide more across the district,” said Stephen. EDUCATION PACKAGE The team also conducted a test run of an associated online education package – a snapshot of the ovarian cancer pathway – to a Lennox Head general practice. “It included a case study to walk people through. Dr Koppe facilitated a couple of sessions at the Women’s Cancer Conferences late last year. We used that approach to develop something short and sharp in a package that can be accessed online in 15 minutes,” Stephen explained.

TEAM APPROACH Both Stephen and his HealthPathways development colleague Dr Hilton Koppe are keen to emphasise the excellent teamwork demonstrated during the process and the value of building rapport and relationships when collaborating on HealthPathways. This work involved visiting each other at different work sites and building a team culture rather than a task-oriented approach. “That really paid off because when you need a quick answer you’ve got the rapport there with people willing to respond,” Stephen said. “The interactions with NCPHN staff have been excellent. The team involved demonstrated excellent engagement, an ability to deliver on agreed objectives and strong advocacy on challenging issues. They also provided relevant and insightful advice to enable optimal focus and delivery of project deliverables, as well as those high-value goals that only

become apparent within the project cycle,” he added. Hilton worked mostly with Project Lead Lisa Delaney and explained how that process unfolded. “So Lisa took the state-based, best evidence-based guidelines and then we worked together to put that into a structure that fitted HealthPathways. That was about applying best practice and how that would work in our region. She spoke a lot with the subject matter experts (oncologists etc) which was really helpful and together we developed several cancer-specific pathways and a number of associated pathways that integrate with the cancer ones. “The process has evolved quite a lot and that’s the beauty of HealthPathways,

they are living documents.” Hilton is sure that GPs will look at the Psychosocial Care in Cancer pathway and think “Oh my God, this is fantastic!” Such a pathway has not been done before and he’s excited about what has been achieved. RELATIONSHIPS “HealthPathways’ development is a fantastic example of primary care and tertiary care within the LHD working together. A great example of the commitment of both parties to do something that leads to better outcomes for patients. It’s wonderful to see the fruits of working together and the linkages that are produced. “It’s all about Progress = Work x Relationships. You can work really hard but when you have zero relationships you make zero progress. To make progress, you have to build good relationships,” said Hilton. CA N CE R O N T H E N O RT H COA ST

IMMUNOTHERAPY IN ONCOLOGY By Dr Adam Boyce, medical oncologist

dvances in the field of immuneoncology are challenging the traditional therapeutic management of many malignancies. Patients with cancers once deemed untreatable are now achieving sustained responses and improved overall survival. The rate at which new agents, targeting the immune system, are coming on to the market is unprecedented. Many of these agents are now incorporated into current standard of care protocols. Many challenges remain, however, from patient selection, sequencing, cost and novel toxicities. An understanding of the fundamentals of cancer immunotherapy is essential to help guide our patients and keep pace with this rapidly evolving field. An understanding of how tumour cells evade the immune system has been crucial in the development of new targeted therapies. Tumour evasion or tumour editing consists of three main components or the so called three Es: Elimination – initial phase of recogni-

tion and destruction of some cancer cells by T, B and Natural Killer (NK) cells and mediated by cytokines such as IFN α, IFNγ and IL-2. Equilibrium phase – some cancer cell

Dr Adam Boyce

clones persist but others are destroyed by adaptive immune responses driven by CD4+ and CD8+ T cells. Escape phase – where malignant

clones acquire the ability to evade the adaptive immune system. The mechanisms contributing to successful tumour immune escape include: Immune exclusion by altered cytokine expression impeding T cell trafficking to tumour sites Modulation of suppressive CD4+ and CD8+ T cells and induction of regulatory T cell (T-reg) mediated tolerance.

The over expression of negative coregulatory molecules such as PD-1 and other checkpoint inhibitors effectively dampening the T cell response An understanding of these pathways has led to the development of the vast array of available immunologically targeted therapies. The therapeutic approaches include cytokines, T cells (checkpoint inhibitors), manipulation of T cells, oncolytic viruses and vaccines. For the purpose of discussion immune checkpoint inhibition will be discussed.

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CHECKPOINT INHIBITORS The checkpoint inhibitors are immunomodulatory antibodies that act via the PD-1 receptor on the T lymphocyte, the PD-L1 receptor on the malignant cell or CTLA-4 pathways. These agents are at present the only immunotherapy agents TGA or PBS listed and are what most patients know as immunotherapy. CTLA-4: This is a negative inhibitor of T

CA N CE R O N T H E N O RT H COA ST

cell activation. When present on the surface of CD4+ and CD8+ T cells it has an increased affinity for the co-stimulatory receptors on antigen presenting cells (in this case tumours) than for the T cell stimulatory receptors. It is upregulated by IL-12 and IFN gamma release by tumours effectively putting a brake on T cell activation. This can allow uncontrolled tumour proliferation. The CTLA-4 inhibitor Ipilimumab (Yervoy®) was the first checkpoint inhibitor approved due to its ability to improve overall survival in patients with advanced melanoma. Recent trials have led to its FDA approval for adjuvant treatment for high risk melanoma as a superior alternative to interferon. In Australia it has PBS listing as first line therapy for advanced melanoma or sequentially to PD-1 and PD-L1 inhibitors. Its combination with PD-1 inhibitors will be discussed later. PD-1 and PD-L1: The trans-membrane

protein Programmed cell death 1 (PD1) is an inhibitory molecule found on T cells, B cells and NK cells. It binds to the PD-1 Ligand (PD-L1) which is expressed on the surface of many tumour cells. This interaction between PD-1 and PD-L1 inhibits tumour cell apoptosis, exhausts T effector cells and helps convert them to T reg cells. Tumour cells over expressing PD-L1 are therefore abler to evade immune checking. There are a number of PD-1 and PD-L1 inhibitors available for use in Australia. These include: Pembrolizumab (Keytruda®): A PD-1

inhibitor is currently PBS reimbursed for first line treatment of advanced and metastatic melanoma. Recent data from the Keynote -001 trial, presented at the ASCO 2018 meeting, has shown the 5-year overall survival in treatment naïve patients with advanced melanoma to be 41%. Pembrolizumab is also available via a compassionate access scheme for

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EXCITING DEVELOPMENTS WITH THE USE OF NIVOLUMAB IN THE ADJUVANT SETTING IN MELANOMA, FOR HIGH RISK PATIENTS, ARE ALSO POTENTIALLY PRACTICE CHANGING

Compassionate access is available to use in combination with ipilimumab for first line therapy of advanced melanoma. Preliminary data from CheckMate 067 trial is showing median overall survival rates of 58% in patients treated with combined therapy. Exciting developments with the use of nivolumab in the adjuvant setting in melanoma, for high risk patients, are also potentially practice changing. Atezolizumab (Tecentriq®): A PD-L1

inhibitor is approved for use as second line treatment of non-small cell lung cancer Durvalumab (Imfinzi®): A PD-L1

patients with advanced or metastatic non-small cell lung cancer with tumours exhibiting more than 50% PD-L1 expression. Results from the KEYNOTE-024 study, comparing first line pembrolizumab with platinum based chemotherapy in this group, showed that response rates (44.8% v 27.8%) and median progression free survival (10.3mo v 6.7mo) were higher in those treated with pembrolizumab. Pembrolizumab is also approved for use in Hodgkin’s lymphoma.

inhibitor is available on compassionate access for the treatment of locally advanced non-small cell lung cancer, following radical intent concurrent chemoradiotherapy. This is based on data from the PACIFIC trial where patients were allocated to receive durvalumab or placebo (standard of care has been observation) for 12 months following initial therapy. In the durvalumab arm the median progression free survival (PFS) l time was 16.8 months compared to 5.6 months in the placebo. The 18-month PFS rate was 44.2% vs 27%. The median time to death or distant metastasis was 23.2 months vs 14.6 months. These results are considered practice-changing and will offer this group of patients additional hope.

Nivolumab (Opdivo®): A PD-1

Avelumab (Bavencio®): A PD-L1 in-

inhibitor is PBS reimbursed as second line therapy in advanced and metastatic non-small cell lung cancer. Results from the CheckMate 017 study of nivolumab vs Docetaxel, as second line therapy in squamous cell carcinoma, showed a 42% vs 24% 1 yr overall survival benefit. For non-squamous cell tumours CheckMate-057 showed a 51% v 39% 1 yr overall survival benefit. Nivolumab is PBS reimbursed as treatment for renal cell carcinoma following failure or intolerance to first line tyrosine kinase inhibitors. The results from the CheckMate -025 study, of nivolumab versus everolimus, showed a 25-month median overall survival in the nivolumab arm versus 19.6 months in the everolimus arm. PBS reimbursement is also available as second line therapy for head and neck squamous cell carcinoma following failure of platinum based therapy.

hibitor has TGA approval for use in first line and refractory metastatic merkel cell carcinoma of the skin. In what is a very difficult to treat and aggressive malignancy response rates were as high as 71% among those with more than 6 months follow up and the duration of response was greater than 6 months in 83% of responders. As tumour diagnostics improve, the spectrum of activity for the checkpoint inhibitors is likely to broaden. Tumours that over express PD-L1, and tumours with so called high tumour mutation load are more likely to respond to checkpoint inhibition. In colorectal cancer, for example, immunotherapy has not had a major clinical impact, but for patients with mismatch repair deficiency (MSI-high) agents such as nivolumab and pembrolizumab are showing promise with up to 50% response seen in phase II trials. Continued next page

PATIENTS USE COLD CAPS TO REDUCE HAIR LOSS

From page 18

TOXICITY Whilst generally superior to chemotherapy with regards toxicity, severe reactions can occur. These reactions, or Immunerelated adverse events (IrAEs), are the result of auto-immune inflammation due to over-activation of T cells. IrAEs can lead to early cessation of therapy and in some cases hospitalisation or even death. Most IrAEs are however usually mild. Treatment for more severe reactions requires high doses of steroids and occasionally disease modifying agents such

Nurse Kylie Lindsay fitting Jodee with the Paxman cap

IT’S QUITE A COMMITMENT TO USE THE COLD CAP AS THE TIME SPENT AT EACH CHEMOTHERAPY SESSION IS INCREASED BY TWO HOURS temperature of the cap. “One lady who started using the cold cap said within 10 minutes that she couldn’t stand the cold. The first 10 to 20 minutes are the most uncomfortable and then the scalp goes numb,” said Kylie. When HealthSpeak visited, patient Jodee was using the cold cap during her eighth chemotherapy session. She elected to use the cold cap so that some of her family wouldn’t be aware that she was going through cancer treatment. After Kylie fitted Jodee with the

as mycophenolate and Infliximab. There are no effective ways to predict IrAEs, but it needs to be noted that patients in clinical trials are usually highly selected and those with pre-existing auto-immune conditions were excluded. Care when treating such patients is needed as the likelihood of a severe reaction or reactivation of auto-immune disease is higher. The most common adverse events are gastrointestinal, skin, hepatic and endocrine disorders. Toxicities are significantly more common in patients treated with combined

silicone cap with the coolant running through it and then ensured the soft outer cap was properly in place, she put some warm blankets around her to combat the cold. The inner cap must be fitted tightly and make contact with the entire scalp for best results. While Jodee started with very thick hair, it’s now thinner but looks even. She is grateful for the time Kylie spends setting up the machine and helping with her treatment sessions. For her part, Kylie’s reward is seeing her patients so happy to be keeping their hair. Patients can talk to their oncologist about whether their treatment is suitable for combining with the Paxman system and then it will be noted on their referral. When the patient arrives at their first chemo treatment the cold cap can be ready for them to use.

CA N CE R O N T H E N O RT H COA ST

undraising by not for profit organisation Jodie’s Inspiration has resulted in two Paxman Scalp Cooling System machines being made available to oncology patients at Lismore Base Hospital. St Vincent’s Private Hospital in Lismore also has two machines. The Paxman Scalp Cooling System reduces hair loss in patients undergoing chemotherapy treatment. Damage to the hair follicle can be alleviated through use of the 'cold cap'. It works by reducing the temperature of the scalp by a few degrees immediately before, during and after chemotherapy. This reduces the blood flow to hair follicles which may prevent hair loss. The company states that hair loss is still going to be 30 to 50% with the use of the cold cap, but the scalp cooler can help hair grow back quicker. HealthSpeak visited the chemotherapy unit at Lismore Base Hospital and met the cold caps resident ‘champion’ nurse Kylie Lindsay. Kylie said that since the Paxman machines arrived six patients had made use of them. “It’s quite a commitment to use the cold cap as the time spent at each chemotherapy session is increased by two hours. The patient sits through half an hour of scalp cooling before their treatment starts and after treatment they have to leave the cooler on for another hour and a half,” Kylie explained. “But one 19-year old girl with Hodgkin’s Lymphoma used the cap with pleasing results, even though it’s not designed with haematology patients in mind,” she added. However, using the cold cap does bring an added level of discomfort, but only while the scalp adjusts to the cold

To find out more about the Paxman system go to: https://paxmanscalpcooling.com/scalp-cooling

PD-1/PD-L1 and CTLA-4 inhibition. Grade 3 or 4 toxicity rates are approximately 3% in PD-1 and PD-L1 monotherapy, 9% in ipilimumab treated patients and 19%in combination treated patients. For example rates of diarrhoea are as high as 44% in combination immunotherapy. Other common side effects include abnormalities of liver function, skin rash, alterations in endocrine function (most commonly thyroid) pneumonitis, rheumatological effects and fatigue. More uncommonly neurological toxicity such as Guillain-Barre syndrome may occur.

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HEALTHSPEAK

AUGUST 2018

Goori Grapevine Bullinah AMS to build new Ballina clinic

he Board of the Bullinah Aboriginal Health Service (BAHS) has announced that the recent purchase of land in Ballina that will eventually will become the home of a purposebuilt culturally appropriate health facility. ‘It’s been a great week, we have been saving funds for over 10 years, so, it’s a long time coming’,” Board Chair Brenda Holt. BAHS was established in 2008 to work with partners in the Ballina, Byron Bay, Mullumbimby, and Evans Heads areas, to improve health and wellbeing outcomes of Aboriginal People and their families. Founding and current Board member Aunty Nancy Walke

is extremely excited about the purchase. “We will be holding consultations with our Aboriginal community as it’s important to get their input into the shape and design of this new building,” she said. Board Member Dave Kapeen, believes it’s really important to have a cultural theme throughout the building. “Hopefully we can get enough funds together to house a cultural art centre as well that will showcase our local artists, and maybe a coffee shop too that our young ones can work in.” The site for the new building will be on the corner of Grant and Tamar Streets in Ballina.

Aboriginal health research centre opens in Perth A new centre to boost Aboriginal health by fasttracking social and cultural research has opened at Murdoch University in Perth. Indigenous Health Minister Ken Wyatt said the Ngangk Yira Aboriginal Health and Social Equity Research Centre promises new methods of tackling Closing the Gap challenges. “This unique centre aligns strongly with the Turnbull Government’s holistic, whole-of-life approach to improving First Peoples’ health,” said Minister Wyatt. “Ngangk Yira means ‘rising sun’ in Noongar and aims to expose and reduce the broader social inequities that affect the health of many of our people. “Targeting and understanding the social and cultural determinants of health is crucial, because

these factors can account for up to half the life expectancy gap between Aboriginal and nonAboriginal Australians.” Minister Wyatt said the new centre would focus on practical health solutions, including research into the importance of cultural respect, education and equality. “Ngangk Yira’s Birthing on Noongar Boodjar study has already revealed a shortage of culturally secure maternity care in hospitals,” Minister Wyatt said. “The centre’s work is about giving children the best start in life and the opportunity to reach their full potential as they grow into adults,” he explained.

Bullinah’s Board of Directors celebrates the purchase. From left: Paul Simpson, Aunty Nancy Walke, Brenda Holt, Dave Kapeen and Emma Walke.

Indigenous Trainee of the year

asino-based Dental Assistant trainee, Karri Williams, was awarded the Indigenous Trainee of the Year at the recent Hunter Valley Training Company Excellence Awards. Karri is a trainee with Northern NSW Local Health District (NNSWLHD) Oral Health Services, and completed her traineeship at the Casino Aboriginal Medical Service over the past year. “I was surprised when I was told I’d won the award,” Karri said. “It’s an award that my family and I are proud of and that I achieved doing something I really enjoy.” In partnership with Bulgarr Ngaru Aboriginal Medical Service, NNSWLHD supports local indigenous trainees to complete their training in regional locations through the dental assistant training program. Tara Reade, Dental Assistant Site Leader at Casino Aboriginal Medical Service praised Karri’s

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Karri Williams

teamwork and calm nature. “Karri adapted so well to the different duties as a Dental Assistant, assisting in the child clinic as well as assisting with school assessments,” Tara said. “She was popular among our child patients who find her cheerful and calming in a reassuring manner.” Since completing her traineeship, Karri is now working with the Grafton Oral Health Service. healthspeak August 2018

Aboriginal Chronic Disease Conference builds workforce capacity

orth Coast Primary Health Network’s Aboriginal health team hosted its inaugural Aboriginal Chronic Disease Conference in late May on the Mid North Coast, with more than 130 people attending. The conference was held during National Reconciliation Week. The two-day conference aimed to enhance existing skills and capacity within the Aboriginal health workforce. The first day was a Red Dust healing workshop at Boambee Community centre. Facilitator Tom Powell used an ancient Aboriginal perspective to support people to explore and heal unresolved hurt, anger, grief, loss and other life issues. From here they can make better life choices. Day two saw participants take part in an Origins of Chronic disease workshop. The workshop focused on the impact of trauma, abuse and neglect on the development of chronic disease and practical ways in which

Some conference participants engaged in small group work.

Aboriginal Outreach Workers can make use of this knowledge. NCPHN also engaged Gumbaynggirr artist Brenton Lugnan to attend the conference to draw and bring to life to the conference themes. Brenton’s artwork will be used to remember the conference and recognise the importance of National Reconciliation Week.

The conference aimed to enhance existing skills and capacity within the Aboriginal health workforce

Panel examines kidney transplant barriers An expert panel will investigate and identify any barriers faced by First Nations people in need of kidney donations, to help ensure equity of access to lifesaving and life changing transplants. Indigenous Health Minister Ken Wyatt AM said Government funding of $250,000 would allow the Transplantation Society of Australia and New Zealand to lead a comprehensive review into the hurdles, service gaps and practical challenges faced by Aboriginal and Torres Strait Islander patients receiving treatment for renal disease. “Ensuring transplant equity is fundamental to fairness and Closing the Gap in health equality,” Minister Wyatt said.

Dietitian students help create new bush tucker garden

n June 5, Stage One of a new Bush Tucker Garden was launched and planted within the Lismore Community Garden. The project came to be through the work of student dietitians Monique Jephcote and Maureen Henen from Griffith University. The students collaborated with Bundjalung Elders, Aboriginal organisations and the Garden, under the guidance of Jullums Aboriginal Medical Service in Lismore. Monique and Maureen are also supported by the University Centre for Rural Health (UCRH) who organised their work placements. August 2018 healthspeak

Planting bush tucker plants on the launch day in Lismore.

Jullums’ General Manager Vickie Williams said the project fitted in well with the Aboriginal Medical Service’s mission

to educate and promote health and wellbeing to the Aboriginal community. “We want to encourage

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people to take responsibility for their own health through our guidance and the Bush Tucker Garden is a great way to promote the joy of growing your own fruit and vegetables,” said Vickie. Thanks also to Keshia Gordon and the WOC team from Ngulingah Land Council who helped prepare the planting areas for the Launch. They have also partnered with Lismore Community Garden for the long-term establishment of the garden. Over the longer term, the garden will feature artworks including totem poles (donated by Lismore City Council) and painted mosaic tiles will be used to create community ownership of the garden. 21

SCU Health Clinic: Integrating service, education and research By Professor Iain Graham Dean, School of Health and Human Sciences Southern Cross University

he medical practice at Southern Cross University Health Clinic has seen exponential patient growth in recent years. The services provided are bulk-billed and the clinic welcomes the wider community. The practice hosts four GPs, one general surgeon, one nurse Practice Manager and three Registered Nurses. They support inter-professional learning for a range of health students. The team is committed to patient-centred care and quality improvement. They are currently working closely with North Coast Primary Health Network on the Winter Strategy in collaboration with

the Northern New South Wales Local Health District (NNSWLHD). This clinic is excited to welcome our first specialist, Dr Richard Arnot, a General Surgeon. He is undertaking minor surgical procedures (including skin cancer). All referrals are welcome and there is no out of pocket expense to the patient. Patients can access three nurse-led clinics in Aboriginal Health, Diabetes and Asthma/ COPD with a plan to extend these services. These clinics allow for dedicated coordination of patient care, assisting patients’ health literacy, selfmanagement and health coaching to support the patients’ to reach their health care goals. The clinic’s nurses work closely with the GPs in managing the patient’s chronic health conditions.

Affordable access to psychiatric services has proven to be a challenge for many of our patients experiencing mental health issues. On patient recommendation our nurses have engaged the services of ‘Dokotela’ allowing access to a bulk billing Psychiatry telehealth service, which has been well received by many of our patients. Our nurses and GPs are integral to the University’s work health and safety immunisation program for staff and students

vaccinating in excess of 500 students and staff this year. We are making progress on My Health Record and are registered for the Orion Shared Care Integrated care project with the NNSWLHD and NCPHN. We are committed to research and evidence based practice. Our nurses will be participating in the EPIK research project: Evaluating a training program for Practice nurses in early Identification and management of chronic kidney disease. The work has been presented at various national conferences over the last two years. GP Dr Rosemary Craig has two pilot studies in progress. Better Osteogenesis Needs Exercise – Australian Indigenous Dance (BONE-AID), and a study using a weak magnetic dressing after skin excision.

Link-me trial of mental health care benefiting patients

orth Coast Primary Health (NCPHN) is trialling Link-me, a new approach to stepped mental health care in six general practices in Coffs Harbour and Port Macquarie. The approach triages mental health care levels of need and provides more intensive support where it is required. To do this, patients in the waiting room are offered a short survey on an iPad which allocates their care needs to either a mild, moderate or a severe category. For research and evaluation purposes they are then randomly allocated to either an intervention group or a control group. Care Navigators then work with trial participants in the intervention group to access support for their severe and complex mental health issues. The Care Navigators are based in each participating general practice to meet with the allocated 22

From left: Maria Potiriadis, University of Melbourne; and the Linkme team: Steven Mann, Mathan Maglaya, Philippa Visser, Angela Wallace, Kerry Marden, Linnéa Kettel and Sujeeva Sweeney.

Link-me participants and help them identify what they would like to change or what services might be most relevant to their care. This arrangement also allows them to collaborate with the participant’s usual GP as part of the patient’s ongoing care and to facilitate access to services not usually accessible for the patient. The trial concludes 30 December 2018 and participants will

be surveyed at regular intervals to measure their mental health outcomes. Initial feedback indicates patients are benefiting from the Link-me trial and services provided by the Care Navigators. “I’m not only feeling stronger and more confident but the best feeling is having the dark clouds leave and feel a sense of happiness within myself…I know now

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through guidance from Link-me that I have an inner strength and new skills and tools which I will never stop using so I’m the one in control of my depression and anxiety and not the other way around.” Link-me is a randomised controlled trial and a collaboration between the University of Melbourne, North Coast PHN, Brisbane North PHN and North West Melbourne PHN and funded by the Federal Department of Health. More Information: https://medicine.unimelb. edu.au/research-groups/ general-practice-research/ mental-health-program/link-mea-randomised-controlled-trial-ofa-systematic-model-of-steppedmental-health-care-in-generalpractice blogs.unimelb.edu.au/phn-leadsite-project

healthspeak August 2018

Program supports patients to go from methadone to buprenorphine By Melissa Gulbin

oni Newland had relapsed back to using heroin after two and a half years in recovery, when she decided at 27 to reduce from buprenorphine at The Buttery and be entirely free from opioid substitutes. Speaking from Thailand, the location of the rehabilitation facility where she works as a support worker, Boni is a world away from her former life using heroin and opiate substitutes. “I had been to jail. I was dying. It was a life of prostitution, heroin, benzos, my life was on the line,” she says. “I relapsed on heroin after two and a half years clean the first time. When I was relapsing I was on methadone too. In order to come off the methadone I came to Lismore, swapped from methadone to buprenorphine, so I could come to The Buttery and get clean.” Boni decided to undertake The Buttery’s Maintenance to Abstinence (MTA) Program, one of only two residential facilities in Australia for people who wish to withdraw from an opiate maintenance program to pursue an abstinent-based lifestyle. “People call methadone the ‘liquid handcuffs’ for a reason. When I was on methadone and suboxone, it was like I was covering myself with a sleeping bag and the drugs took away the ability to feel human. It also meant I couldn’t travel.” The program’s Therapeutic Community modeI was integral to Boni’s recovery. “What fuels addiction is isolation – the solution is connection. The residential group setting made me feel I wasn’t alone, I wasn’t misunderstood. Having support workers at The Buttery with a lived experience in recovery was August 2018 healthspeak

What fuels addiction is isolation – the solution is connection

Boni Newland on the road.

vital. “Addiction is a hopeless state of mind and body. I think what I offer now as a support worker is hope. I am passionate about recovery. I want to inspire people. “I think the medical community fears abstinence. Doctors fear that if you reduce, you will be at greater risk of overdose, which I guess is valid, but I think abstinence needs to be recognised as a solution. “I’ve had doctors want

to throw methadone at me. In reality, there aren’t a lot of people who are just on methadone. They are usually on other drugs. It’s stopping one evil for another. There needs to be more support, more time, effort and care and non-judgemental approaches for people in recovery,” she says. The Buttery’s Residential Programs Manager Trent Rees says the age of the average Methadone user is increasing. “It’s not unusual to see people

who have been on methadone for 20 years or more. We’re not saying that people can’t live effective lives, but I think there is a lack of awareness – both in the medical and recovery communities – of abstinence options. “Boni’s story shows how coming off substitutes can change your life. At the very least it allows you to travel. A life on opioid substitutes can be very limiting,” Mr Rees says.

Going from Methadone to Buprenorphine Prior to admission, potential residents for The Buttery’s MTA program will need to transfer to subutex or suboxone (buprenorphine), if they are not already maintained on such, in consultation with their current prescriber they need to begin a personalised reduction regime in consultation with Buttery staff. There are two ways this process of transition from methadone to buprenorphine is completed - high or low dose transfers. • High Dose Transfer – recommended to be completed in a detox facility once a participant has reduced to a methadone dose between 60mg to 80mg. Not generally recommended that transfers are attempted on doses higher than 80mg and will unlikely to be supported by a prescriber. Most prescribers would advocate for a dose of less than 70mg before commencing the detox process.

• Low Dose Transfer – can be completed “at home” or through a detox facility and is usually undertaken when a participant is stabilised on a methadone dose of 40mg or less. It is important to note that both processes require the participant to go through a period of time without their methadone dose in order to precipitate withdrawal. This could be anywhere between 36 and 72 hours after the last dose and will vary from individual to individual. It is very important that the participant work closely with their doctor to manage this transition in order to achieve the optimal holding dose of buprenorphine in a timely manner. For more information about MTA: www.buttery.org.au.

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Developing a health workforce profile L ast year North Coast Primary Health Network (NCPHN) contracted Grosvenor Management Consultancy to undertake a North Coast health workforce project involving workforce mapping and data analysis of primary care professionals working in private practice in the region. This work was necessary mainly because no national repository exists with all primary health care providers’ names, professions and contact details. As strange as it may seem, at times NCPHN staff have even had to resort to going through the White Pages to locate allied health professionals. The result of this work is the first known North Coast Primary Health Care Workforce Profile. This revealed an estimated 6200 primary health care professionals working in non-government services across 22 professions and 46 occupation titles. NCPHN was found to be engaging with or having knowledge of 46 per cent of the estimated total primary health care workforce. A strong knowledge of GPs and practice nurses was found to exist as well as a strong local knowledge of occupational therapists, orthotists, pharmacists, podiatrist and psychologists. Local and national knowledge gaps were identified for Aboriginal and Torres Strait Islander workers and health professionals working in RACFs as well as optometrists, oral health professionals and social workers.

Project scope NCPHN’s Acting Director Integration (NNSW) Monika Wheeler explained the scope of the project. “We really wanted to develop a workforce profile of North Coast primary health care providers so we could really get a sense of who the primary health care workforce is and where 24

3043 nurses work in primary care roles across the North Coast.

ready list and records of all the clinicians in their area.

The North Coast is at high risk of GP Objectives shortage with the The objectives of the Project were to investigate: highest number of • The spread and depth of GP vacancies in the primary health care workforce (profile, number, June 2017 some of the gaps might be.” NCPHN is funded to make the health system more coordinated and efficient, so getting a better picture of the workforce is critical to delivering quality, accessible and integrated care where it’s needed. But as Monika explained the lack of a single point system where all health professionals details are available means workforce information has been limited. “So despite it being NCPHN’s core business to engage with primary health care providers we do not have any resource which tells us who all these people are. We’re in a very different position from the Local Health Districts in that the LHDs employ all their clinicians so they have a

type, location, scope of practice and expertise, availability and accessibility) • Challenges and implications for the region’s health care workforce • Primary health care workforce trends and key drivers • How to efficiently and effectively capture, validate and maintain workforce data • Next steps and proposed activities to support the development of NCPHN’s primary health care workforce strategy.

Profile information GPs

It was found there were 659 GPs, including registrars, working in 178 general practices on the North Coast. Most were spread across the major centres. There were 3.4 medical

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practitioners (GPs and medical specialists) per 1000 people on the North Coast. This is lower than the NSW rate of 3.8 per 1,000 people. The North Coast is at high risk of GP shortage with the highest number of GP vacancies in June 2017, according to NSW Rural Doctors Network data. Ageing GPs is also a problem with one in six GPs aged 65 years or more. Primary Care Nurses

It was found there were around 3043 nurses working in primary care across the North Coast. Most were RNs working in residential aged care (1614) and general practice (322). Only 19 per cent were known and/or engaged by NCPHN. The Project Survey confirmed national trends of an ageing nurse workforce with more than 80 per cent of nursing respondents aged 45 and older. Many indicated they held post graduate qualifications in diabetes, midwifery and immunisation. Allied Health Professionals

It was identified that there were

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healthspeak August 2018

Pregnancy doesn’t ‘cure’ endometriosis, so where does this advice come from? By Mike Armour post-doctoral research fellow in women’s health, NICM, Western Sydney University

any Australian women with endometriosis are reporting they’re being advised a reliable treatment or even possible cure for their endometriosis is to “go away and have a baby”. This message is consistent with what women from other countries are also being told by a range of sources. Pregnancy as a natural cure for endometriosis dates back to the early 20th century. However, even into the 1950s and 1960s, when pregnancy was commonly recommended as a treatment for endometriosis, this evidence was based mostly on case reports of women whose endometriosis improved during pregnancy. Case reports are often unusual findings and don’t necessarily reflect what happens to most people. Pregnancy as a treatment for endometriosis does not appear in current international guidelines for the management of endometriosis. It’s also not mentioned as a treatment by Australian pelvic pain specialists and is classed as a “myth” by reputable endometriosis support sites. Endometriosis and the lack of a cure

Endometriosis is the presence of tissue similar to the lining of the uterus outside the uterus itself. Accurate estimates of how many women in Australia have endometriosis are hard to find, but a common figure is around one in 10 women during their reproductive years. While severe pain during the period is a common symptom of endometriosis, it’s so much more than just a “really bad period”. There’s almost no area August 2018 healthspeak

The concept of “calming” these hyperactive pain pathways is an important strategy in treating chronic endometriosis pain

of women’s lives that is not negatively affected by the condition. Current medical treatments, often using hormone therapy, are not always effective. And the side effects of many of the hormonal treatments can be particularly unpleasant. Excision surgery, in which the endometrial lesions are cut away, is the most effective current treatment. Unfortunately, even surgery is not always successful with around 50% of women having symptoms reoccur after five years. Pregnancy, pain and the brain

Women with endometriosis, like other chronic pain conditions, have changes in the way their brains process pain. Nerves, especially in the pelvis, are also more sensitive than in women without chronic pain. The concept of “calming” these hyperactive pain pathways is an important strategy in treating

chronic endometriosis pain. Each time menstruation occurs it irritates these sensitive nerves and reinforces these pain pathways. One way to prevent this can be by stopping regular menstruation entirely. This is a key reason women with endometriosis are so often treated with continuous use of hormonal contraceptives. During pregnancy there’s also a suppression of menstruation. So it’s possible during pregnancy there will be a reduction in endometriosis-related pain. It’s also just as possible pregnancy will make endometriosis-related pain worse, due to extra pressure on these sensitive pelvic nerves. We just don’t have the research to answer this. After giving birth, it’s quite possible the pain, if it had decreased, will return. This is especially true once women start having regular periods again, as there’s no evidence pregnancy shrinks endometrial lesions or

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changes pain processing in the long term, both major drivers of endometriosis pain. Pregnancy as a treatment?

Pregnancy might help reduce endometriosis symptoms, if only temporarily. But women with endometriosis often rightly feel upset and offended when advised to have a baby as a treatment strategy. There are also risks involved, as women with endometriosis are more likely to have pre-term births, increased rates of caesarean sections and an increased risk of miscarriage. Women shouldn’t have to bring another human into the world to relieve the pain of endometriosis. This is why we need to prioritise understanding the cause of endometriosis, finding effective treatments and eventually a cure. Published with kind permission from The Conversation – www. theconversation.com

Half of Australians have a chronic disease, one quarter have two or more

he two-yearly report card from the Australian Institute of Health and Welfare (AIHW), Australia’s Health 2018, shows a population that’s living longer but with more chronic disease. And this disease is often underpinned by lifestyle factors. Half of Australians have a chronic health condition such as diabetes, heart disease, a mental illness, or cancer. Importantly almost a quarter have two or more chronic conditions, making care particularly complex. Many chronic health conditions share preventable risk factors such as smoking, excessive alcohol consumption, and not getting enough exercise. In fact, around one-third of our disease burden is due to preventable risk factors. AIHW CEO Barry Sandison said when it comes to obesity it’s not just a case of poor diet or exercise habits. Rather a range

From page 24

at least 2500 allied health professionals working on the North Coast. Sixty per cent of these clinicians were known and/or engaged by NCPHN.

Allied health & nursing census Another component of the project involved an allied health and nursing census to garner more basic contact information from the health workforce and more interestingly what their intentions were in terms of their working life. For instance, how long they intended to work in their current role, and whether they planned to up skill or move to a different area of work. More than 500 people responded to the census with about 250 full responses. Some interesting information came out of the census. “Medicare came through as 26

When it comes to obesity it’s not just a case of poor diet or exercise habits

of factors – biological, behavioural, social and environmental – contribute to the likelihood of becoming obese, including rising work hours, the walkability of our environs, increasingly sedentary jobs, larger portion sizes and food advertising.

Improving Indigenous health

a significant barrier to access allied health professionals. For instance, people with chronic diseases can only get five sessions under a chronic disease management plan. This means other visits have to be paid in full, so that’s a real challenge,” said Monika.

North Coast in the future. These include: • Working with other organisations to map nurses and allied health professionals delivering care in NSW Health facilities and private specialists • Collecting and validating data gaps identified in the Workplace Profile • Improving workforce data collection and maintenance • Publishing fact sheets about what primary health care professionals do • Analysing the existing health workforce against population needs and prioritising these in NCPHN’s Needs Assessment data collection • Working with relevant bodies to develop a single approach to allied health regulation • Doing further mapping of clinicians working in

‘Dictionary’ created Another outcome of the Workforce Project is a ‘dictionary’ of allied health and nursing services – no other similar resource exists. This explains the various allied health occupations and what these professionals do.

Project recommendations The project report’s Executive Summary includes recommendations that NCPHN undertake a number of activities to ensure a comprehensive workforce strategy is developed on the

There have been some big improvements in the health of Aboriginal Australians, but challenges remain. Life expectancy has improved and with higher education has come better health outcomes.

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There have also been reductions in smoking rates and alcohol use, as well as improvement in child death rates. However the report shows that social factors are key to further progress. Factors such as employment, education and income are responsible for about one-third of the health gap. By comparison, factors such as smoking and obesity account for one-fifth of the health gap. Read the full report here: https://www.aihw.gov.au/reports/ australias-health/

emerging professions such as counsellors, case workers and peer workers • Adopting the Workforce Planning Framework outlined in the report • Establishing a North Coast primary health care workforce planning governance mechanism Overall, this project has enabled NCPHN to identify workforce capacity issues and help build the local health workforce. The entire Project Summary Report can be found at: ncphn.org.au/ health-workforce Since the report commenced, NCPHN has been speaking with the Rural Doctor’s Network, the Northern NSW LHD, and the University Centre for Rural Health about undertaking a collaborative approach to workforce planning on the North Coast. healthspeak August 2018

HAEMATOLOGY: A RAPIDLY CHANGING LANDSCAPE r Louise Imlay-Gillespie is one of four North Coast Cancer Institute haematologists working to care for people at Lismore and Grafton Base Hospitals. Louise told HealthSpeak that with the field of haematology was moving incredibly fast, it’s not possible to quickly summarise all that’s happening in research and treatment. But she’s excited about advances. “The Holy Grail of cancer medicine is to be able to take somebody’s leukaemia or lymphoma out of them, but leave them without the toxicity associated with treatment. A lot of our treatments are a bit like napalm but with all the immunotherapies, all the targeted therapies, all the biologicals, we’re getting better and better at targeting the leukaemia and leaving everything else alone. It’s all in its infancy and that’s what’s so exciting. “Right now there are a lot of trials going on to obtain information about the best drug combinations and when and how to use them.” What’s also improved is the supportive care of patients. “We have much better anti-emetics, pain relief, all those things. If you think about the 1980s chemo, patients would prefer to be dead. It’s such a different landscape now and half of it doesn’t even involve chemotherapy.” With such an array of treatment combinations, Louise emphasised the importance of specialist doctors. “In medicine we used to have a general physician who looked after everything. Now that the sub-specialties are dealing with so much specific knowledge,

Dr Louise ImlayGillespie

RIGHT NOW THERE ARE A LOT OF TRIALS GOING ON TO OBTAIN INFORMATION ABOUT THE BEST DRUG COMBINATIONS AND WHEN AND HOW TO USE THEM speciality doctors are essential to provide the best care.” With such rapid change, Louise is keen to assure GPs that if they have any questions about referrals, follow up of patients or just want to chat about something to do with haematology, then they should pick up the phone and get in touch. Fortunately, along with big change in this field of medicine, more and more haematologists are being engaged by the LHDs in the region to meet the needs

From page 19

The management of toxicity starts with patient education about the types of toxicity and when to present (early if severe). If severe toxicity occurs it is important to initiate treatment early. This should include treatment interruption, early commencement of high dose steroids. With diarrhoea, if colitis is confirmed and refractory, steroids Infliximab therapy should be initiated. With hepatitis early use of mycophenolate should be consid-

of patients. “While the regions have traditionally found it harder to recruit specialists in general, that’s really beginning to change. All of the younger physicians are certainly looking for something other than city life and the lifestyle here is quite attractive. “GPs should be aware that all departments across Lismore Base Hospital are growing and in Haematology we’ve taken on our fourth haematologist in Lismore/ Grafton. We still need more but Tweed has recruited a third haematologist this year, Coffs Harbour will shortly have a third haematologist and Port Macquarie has taken on a third haematologist too.” While Louise appreciates that in the past it may not have been easy to speak to a haematologist on the phone, that’s changed. “Whatever the GP experience has been over the past five years, things are changing quickly and the next five years will be a lot easier. And generally if a GP is not sure what’s happening with their patient, we like to be involved. The more information we have about a patient the better. We can provide insight and some tools. So trying to work together as much as possible is the best way forward.” On Fridays once every other month there is an end of life multidisciplinary meeting at UCRH in Lismore at 7.30am. Normally the GP managing the case presentation is invited to attend, but Louise said health professionals with an interest are certainly welcome to come along too.

C A N C E R O N T H E N O RT H C OA ST

For more information phone Louise on 6620 2416.

ered. Hospitalisation is often required, and involving a multi-disciplinary team of clinicians improves outcomes. In summary, immunotherapy has already become an important component of standard treatment for many malignancies. The immune checkpoint inhibitors are the most available and advanced of these. Other approaches such as vaccines and T cell activation are showing promise but have largely been overshadowed by the success and proliferation of the check-

point inhibitors. Generally toxicity is mild but financial toxicity is high. These agents are extremely expensive and outside of PBS indications, compassionate access or clinical trials remain out of reach to most patients. Precision medicine really is the future. With predictive biomarkers, precision immunotherapy, in combination with other treatment such as chemotherapy and radiotherapy, will lead to improved outcomes.

HEALTHSPEAK

AUGUST 2018

RADIOTHERAPY USES BROADENING ALL THE TIME

Dr Patrick Dwyer with colleague Carol Tinker

NORTH COAST CANCER INSTITUTE RADIATION ONCOLOGIST DR PATRICK DWYER SAT DOWN WITH HEALTHSPEAK TO TALK ABOUT THE CHANGING SCOPE OF RADIOTHERAPY BOTH IN CURATIVE AND PALLIATIVE CANCER TREATMENT. C A N C E R O N T H E N O RT H C OA ST

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he North Coast Cancer Institute is delivering highly technical treatments in a quality controlled environment at no cost to the patient with good allied health support. The treatment offered is comparable to metropolitan centres, although referrals to tertiary institutions are made when necessary. Patrick explained that changes in imaging and radiation treatment delivery have played a key role in the centre being able to deliver a high standard of treatment. “We’re using a lot of information to delineate the target. We’re using MRI and PET SCAN fusion here so we can very accurately target where we need to treat. And we are using techniques such as VMAT to be able to conformally cover the target with the radiation and to limit the dose to normal healthy tissues,” he said. When it comes to lung cancer radiation treatment, the Institute is routinely using four dimensional CT scans to quantify how that tumour moves in that patient when breathing , allowing clinicians to personalise their treatment accordingly. Patrick explained that some recent big developments have been in stereotactic treatment – giving large doses of radiation in just a few sessions. “For example with early stage lung cancers we used to treat patients with six weeks of daily treatment. Now in four or five sessions they receive much higher biologically effective treatments. That

H E A LT H S P E A K

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treatment is called stereotactic ablative radiation therapy (SABR). It gives very good control rates and we’re using that as a first line option for patients with early stage lung cancer that is not operable. “We’re using SABR as part of a clinical trial with other NSW sites and seeing very good local control rates and minimal side effects. The dose gradient drops off very quickly around the tumour so the dose to normal tissues such as the spinal cord, oesophagus and ribs is very acceptable.” The Institute is also delivering SABR for patients with lung metastases. As Patrick explained the palliative care landscape is becoming more complex with more treatment options.

WE’RE USING SABR AS PART OF A CLINICAL TRIAL WITH OTHER NSW SITES AND SEEING VERY GOOD LOCAL CONTROL RATES AND MINIMAL SIDE EFFECTS “Systemic treatments like chemo and immunotherapy are fortunately allowing patients much longer life. We’re now selecting some patients for radiation treatment where previously there would not have been a benefit.” One example is in patients with oligometastatic disease - where cancer cells from the primary tumour travel through the body and form a small number of new tumours in one or two other parts of the body. “Such patients can have a good prognosis if we offer aggressive systemic treatment and with local treatment we can improve progression-free intervals in these patients. We see the disease is turn-

ing more into a chronic disease than an acutely life-limiting cancer.” And for patients with brain metastases, whole brain radiation has evolved to avoid the hippocampus, the part of the brain governing memory. As mentioned, some forms of lung cancer are becoming similar to a chronic disease. “Patents are living good long lives now. And if they get a local flare up sometimes there’s a role for surgery or stereotactic treatment to ‘wake up the immune system’. While that’s all anecdotal and experimental at this stage, you do wonder about whether that’s how things will go as further clinical trial evidence emerges.” A large number of the Institute’s patients are receiving standard palliative care radiation treatment. The most common is bone metastases causing pain. But as in other areas of radiation therapy, palliative care has become broader. “Palliative radiation therapy used to be quite straight forward – treatment delivered quickly to limit pain with most patients not living very long. Now patients are living longer and more advanced treatment can be more complicated to plan and deliver. We’re giving higher doses very accurately, which we weren’t able to do before improvements in imaging and treatment planning.” So keeping up with advances must be a challenge? “That’s the benefit of work groups, both multidisciplinary and within radiation therapy. If someone attends a conference or reads a paper about a new technique then we’ll form a work group that will further the protocol. We’re very mindful of providing high quality services.” Patrick would welcome GP attendance at the Institute’s multidisciplinary meetings.

Flood survey reveals unequal impacts & praise for community focused approach

t has been almost a year since the University Centre for Rural Health (UCRH) launched their ‘Community Recovery After Flood’ survey to investigate community mental health and wellbeing in the Northern Rivers following the devastating floods in March/ April 2017. Initial findings highlighted the overall mental health impacts of the floods, emphasising higher risk of depression, anxiety and post-traumatic stress for those affected by the flood, particularly if a respondent had multiple sites impacted (home, suburb, business/farm, home of significant other), and if they experienced lengthy displacement from their home. These findings can be viewed on the University Centre for Rural Health’s website at http://ucrh.edu.au/after-theflood/. Survey Coordinator Dr Veronica Matthews said further analysis showed certain sectors of the community were more impacted by the flood than others. “Marginalised groups, including recipients of income support, Aboriginal and Torres Strait Islander people, and LGBTQI respondents were more likely to have their homes inundated and to be displaced compared to other respondents.” “Six months after the flood, they were also more likely to report adverse mental health outcomes after taking into account severity of flood damage.” UCRH Director Ross Bailie said that a priority of the project is to provide timely, readily available information to the organisations who can use the data to improve their policies, practices and planning to assist before, during and after a disaster. “These findings have important implications for how we tailor services before and after disasters. We are working with key organisations on our ComAugust 2018 healthspeak

AFTER THE FLOOD

Community recovery in the northern rivers munity Advisory Group to find out how this information can be best used to inform disaster preparedness and response planning. It was great to see our infographic shared with Shadow Prime Minister Bill Shorten by Tweed Shire Council when he visited Murwillumbah in April,” Prof Bailie said. “While our focus is on mental health and wellbeing, our findings are relevant to a broad range of organisations who are involved in emergency management, and so providing feedback

These findings have important implications for how we tailor services before and after disasters from respondents is a priority. Respondents have told us what worked well, what could have been improved, and what they would like to see happen in the future. It is our hope that our research will contribute to better community wellbeing through improving understanding of how community and organisational structures influence people’s ability to recover after natural disasters” Prof Bailie added. The UCRH has received positive feedback from members of its Community Advisory Group for its research: “I was very encouraged by the early interest from UCRH in this study following our devastating

flood in 2017. The quick time frame meant that new information could flow from the process into disaster recovery plans, as well as back into our community to aid the recovery process.” - Isaac Smith, Mayor, Lismore City Council “My hope is that the research can create practical and policy outcomes that build increasing personal and collective preparedness, resilience and self-capacity to reduce the impact on all areas of our community.” - Rik White-

head, Regional Director North Coast / Communication & Engagement, NSW Department of Industry. “Red Cross found the Community Advisory Group useful in a number of ways. As well as providing new information on the mental health impacts of disasters, the Group set a new precedent for the way that we work together locally after an emergency event” - Catherine Martinez, Regional Emergency Services Officer Australian Red Cross.

Help to prevent COPD exacerbations

Have the CHAT with your patients this winter Chronic Obstructive Pulmonary Disease (COPD) exacerbations are the second leading cause of preventable hospitalisations in Australia. Research shows that patients with COPD are more likely to have an exacerbation over winter. ‘Have the CHAT’ is Lung Foundation Australia’s COPD exacerbation campaign for primary care health professionals,

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equipping you with the tools and resources needed to keep patients well and out of hospital during winter. The campaign encourages health professionals to complete a simple six step checklist for each patient with COPD. Now is a great time to CHAT: C – Coughing more than usual H – Harder to breathe than usual A – Any change in sputum colour and/or volume T - Tired more than usual (less active). Resources to support your CHAT may be found here: lungfoundation.com.au/ havethechat Or phone freecall 1800 654 301.

HWNS offers specialist services for patients with additional needs

ost North Coasters would know House with No Steps (HWNS) through its Summerland House Farm at Alstonville. But did you know that HWNS offers a range of specialist services for people with particular needs? HWNS Enhanced Supports Manager Michelle Gray sat down with HealthSpeak to outline the specialist supports they can provide. All of their services are available at clinic locations or through home visits. Early Childhood Intervention Supports

HWNS is partnered with Summerland Early Childhood Intervention, who provide specialised support and services for infants and young children (aged 0-6yrs) with a disability and/or developmental delay, and their families. After this they can use the Enhanced Support Service if they need further support. This means that people don’t have to change therapists if they are comfortable working with someone and have established a good relationship.

People don’t have to change therapists if they are comfortable working with someone and have established a good relationship

A specialised feeding service is available using Occupational Therapy and Speech Pathology. It is available from 0 to 12 years. Children can be supported with a range of feeding difficulties including breast and bottle feeding, transition to solids, fussy/picky eaters, or food aversions. Enhanced Supports Service

This service is available for people from 7 to 65 years and can be accessed through the NDIS (HWNS is a registered provider) when needed to assist someone to meet their goals.

COMPASSIONED FOCUSED THERAPY: A BOOK FOR THERAPISTS The University Centre for Rural Health’s Prof James Bennett-Levy is a co-author of a new book to encourage therapists to include compassion-focused therapy in their personal practice in both training and personal development. The book is titled Experiencing CompassionFocused Therapy from the Inside Out and was written by Russell L. Kolts, Tobyn Bell, James Bennett-Levy and Chris Irons. James is a recognised

leader in the field of therapist training with more than 40 publications and five books to his name. While up to now the question of whether therapists should ‘walk the

Occupational Therapy and Speech Pathology can also be accessed through chronic disease management care plans or by paying private fees. Using a multidisciplinary team approach, HWNS offers the following support for individuals and their families: • Specialist behaviour support – working to develop strategies to better support the individual and reduce behaviours of concern. • Education in sexuality and relationships, emotional regulation, social skills talk’ has been largely a matter of tradition and belief, over the past year James has been constructing a theoretical and empirical case for the inclusion of a personal compassionfocused practice for therapists. The new book has everything a therapist needs to successfully include this practice which not only encourages personal development but provides a powerful self-care tool for overworked health professionals. James will be launching the book at the UCRH in Lismore on 16 August at 4pm. It is available online at various book outlets.

a publication of North Coast Primary Health Network

development and anger management. • Allied health therapy – includes Occupational Therapy, Speech Pathology, psychology, social work and other allied health support. • Support Coordination – this is a funded support under the NDIS to help individuals connect with local community and networks, build skills and resilience. Educating & supporting families

In these early stages of the NDIS scheme, HWNS is happy to talk to people, families and GPs about access to the scheme or the types of support funded. Michelle said sometimes there’s understandable confusion around what is funded through the NDIS, what is funded through health and what is funded through education. And that’s where HWNS can help. “We’re excited to have this talented and committed team operating on the North Coast. It is great to have the opportunity to work closely with other experienced colleagues to support people with complex needs and their families achieve great outcomes,” she said. For more information or to make an appointment 1300 538 746. Or email: enquiries@hwns.com.au

healthspeak August 2018

Examining the cost of cancer finance David Tomlinson

ustralia has the highest age-adjusted cancer rate in the world. Half of all Australians will develop cancer and one in five will die from it. Cancer is the leading cause of death in Australia. In 2014, 44,000 people died from the disease and this number is on the increase. While this is alarming, there is some good news. We also have cancer survival outcomes equal to the best in the world. Australia's one-year survival rate for all cancers combined is 81 per cent and overall five-year relative cancer survival rates are more than 66 per cent. In addition, the death rate for each 100,000 people has fallen by 24 per cent over the past 30 years. This success rate is put down to high levels of investment in cancer detection, screening, treatments and medical research. Treatments are working. But the cost is high and it is rising more rapidly than the economy is growing, with economic consequences. In Australia cancer costs more than $4.5 billion annually in August 2018 healthspeak

Questions arise such as: How do we ensure value for money? What is a life worth? Are all lives of equal value?

health system costs and much more in terms of lost productivity and suffering. Health jurisdictions are struggling with soaring health care costs, leading to calls for a change in more effective health spending. This would mean better targeting, and in some cases, rationing. Hard choices will have to be made. Questions arise such as: How do we ensure value for money? What is a life worth? Are all lives of equal value? The cost of new cancer drugs

can be hundreds of thousands of dollars for one treatment. Thousands more drugs are in the pipeline and the cost of new drugs is rising at more than 33 per cent a year. Cancer drugs consume a third of the total treatment expenditure but are only responsible for five per cent of improvement in patients. Surgery and radiotherapy are responsible for the bulk of the improvement. The difficulty comes with deciding the best value for money. How, for example, do you compare the cost of a hip replacement for an older person that may give years of pain-free life with a similar cost for a cancer drug that may extend life by 12 months? What about spending more on prevention where there is a much higher return on investment? In an attempt to measure value for money in the case of cancer drugs, the Pharmaceutical Benefits Advisory Committee (PBAC) uses a cost-benefit approach called the Quality Adjust Life Year (QALY) to determine if the drug should be subsidised. One QALY is a

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year of life lived without any ill health. For example, if a new drug adds one QALY then it can be costed at say $60,000. A judgement then has to be made to determine if the cost is too high. Unlike other countries, the PBAC does not have a rigid cost threshold over which new drugs would be rejected. This gives flexibility, but as drug costs soar, tighter guidelines may be needed. Perversely, if an expensive new drug can benefit a lot of people it may be rejected simply on budgetary grounds. The QALY approach has received criticism because it is in some ways unrealistic. It assumes an otherwise healthy patient without pain acquires a cancer that can be treated and brought back to good health. However many patients have multiple conditions unrelated to cancer. Should they receive expensive drugs to treat cancer when they could well die of heart disease or something else? Should the money be spent on someone who is otherwise healthier? If so, then all lives are not equal. And should there be an absolute amount spent on drugs when the money could be used for preventative measures that would add many QALYs to the population. A single drug treatment may extend the life of a cancer sufferer for two years or so but if that money was spent on say mosquito nets in Asia or Africa, the return in QALYs would be many times greater. The answers to these questions are political and based in ethics but the conversation will have to be held with the community. 31

Research: the effect of rural placements on student intentions to practice in rural areas Since 2001, the University Department for Rural Health (URDH) in Lismore has been welcoming health students from metropolitan universities for work placements. Recently, research involving a national study of students undertaking placements at 10 UDRHs across Australia has been published. HealthSpeak spoke to two authors of the research from Lismore’s UDRH – Dr Sabrina Pit and Ms Frances Barraclough about the findings.

his original research is the first national work done looking at student experiences across Australian Departments of Rural Health. Projected health workforce shortages in rural and remote Australia have driven the Australian Government to invest in strategies that engage more undergraduate health students in rural and remote placements. The aims of this study were to investigate the lived experience of medical, nursing and allied health students with rural and remote placements, their satisfaction with the placement and their post-placement intention to enter rural practice. A cross-sectional survey was conducted of more than 3000 medical, nursing and allied health students on UDRH placements between July 2014 and November 2015. Frances described her involvement with the analysis of the qualitative data which included descriptions from students about their preparation and support whilst on placement, their rural or remote experience, rural lifestyle and descriptions of belonging to the community The diagram below provides a good summary of the drivers of student satisfaction during rural placements. 32

Some students had not been rural before, so it’s a big deal for them to leave their families and travel to an unfamiliar environment A second paper that reported on quantitative analyses confirmed the qualitative analyses showing that those satisfied with their placement had a 2.33 higher odds of rural practice intention than others. In summary, students satisfied with the Indigenous cultural training they received, their placement supervision, access to educational resources and accommodation had higher overall odds of overall satisfaction and rural practice intention. (http://onlinelibrary.wiley. com/doi/10.1111/ajr.12375/ epdf)

Frances said most students felt well prepared for their placement. The results of the survey validated the importance of UDRHs providing a welcoming and supportive learning environment and authentic interprofessional opportunities. Students valued living and interacting with other students reinforcing interprofessional collaboration. Also significant was a feeling that they were part of the community. “Some students had not been rural before, so it’s a big deal for them to leave their families and travel a long way to an unfamiliar environment. Students need to have ongoing support and to feel part of the community, part of the UDRH. If we don’t successfully engage and support students, they may not choose to go rural again.’ According to Sabrina, the strongest predictor of becoming a rural practitioner is the student’s satisfaction with their clinical supervisors. “The quality of the education and supervision cannot be underestimated. So if we

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have great clinical educators that is helpful. To attract high quality educators is important; educators are role models and students often feel quite connected to them.” Unlike city placements, students also indicated they appreciated the variety of patient presentations and access in rural placements. Most felt more engaged than during a city placement. Sabrina and Frances said the research indicated that more could be done across Australia to ensure fruitful social interactions for students. The research data will now be used to look at the rural experiences of nursing students only, allied health students only. This research was published in the Australian Journal of Rural Health (2017) and The Journal of Multidisciplinary Healthcare (2018). Source: https://www.dovepress. com/ruralization-of-studentshorizons-insights-intoaustralian-health-prof-peerreviewed-fulltext-article-JMDH

healthspeak August 2018

Was Grandma right? Boiled to death

randma trod a hard path. Her century was interrupted by two global wars and the Great Depression. Her main concern was less about the best nutritional options for her family and more about finding food for the table. Typical Grandma had a vegie garden in the backyard, possibly the only source of fresh food for her family. And what did she do with her fresh vegies? She boiled the crap out of them, actually the goodness. In today’s vernacular, that includes bioflavonoids, vitamins, terpenes, probiotics, fibre and wonders yet to be discovered. ‘Boiled vegetables ruined my life,’ complained an elderly correspondent. I myself can recall, as a child of the 1950s, throwing my flaccid, pale tasteless boiled vegies out the window while Mother wasn’t looking and then filling up on sugary stuff. Grandma was only following the rules. A New Zealand newspaper, the ‘Star’, in 1902 published an article, ‘How to Cook Vegetables’. It advised that ‘Carrots when young and tender, should be boiled for three-quarters of an hour. When August 2018 healthspeak

Lean vegetarian children were crowding hungrily around my sausage sizzle old, they require another quarter. The same rule holds good for onions. Peas and asparagus should be boiled for 20 to 25 minutes.’ This lack of nutritional awareness was reflected in the medical world. Older doctors will attest that the medical syllabus contained nothing about food and health. The body did its own arithmetic - although I do recall a biochemistry professor in a lecture on the confusing Krebs Cycle. This is 1965. The roguish Prof, Bill Hensley, threw in one sentence of clarity. ‘Sugar is as natural to the body as smog’. It may have been his response to a sweet-talking radio ad at the

light airs David Miller

time. ‘Sugar - a natural part of life’. Seven years later, in a London hospital, I recall a lunchtime entertainment lecture for resident doctors featuring an eccentric Professor, Denis Burkitt. Just returned from darkest Africa, his slideshow showed the poo of various animals, including humans. He was very excited to point out the different appearance in those with dietary fibre fluffy and soft, compared to the ‘toothpaste’ faeces of low fibre diets common in British culture. He postulated a connection with bowel cancer. The allknowing young doctors laughed up our sleeves. Asian cooking has never taken the boiling path but it was only the arrival of the Greeks and Italians in the 1960s that delivered Australia from English stodge. Before that time, the only olive oil was found in the bathroom cupboard - Faulding’s - ‘for medicinal use only’. Garlic eaters were regarded with abhorrence. One day my older sister (who had a Latin lover) brought home some yogurt. I asked her ‘How can you eat

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solid sour milk?’ Only recently have the health benefits of the Mediterranean diet become mainstream. When I came to live and practice in 1970s Mullumbimby, I was invited to eat with my new hippy friends. I thought it a bit odd that they preferred their vegetables raw, steamed or stir-fried. Never boiled, which seemed a bit reactionary. Vegetables were vital to the alternative culture because meat was mostly not included. Early on, invited to a barbeque in Main Arm, I arrived with sausages and chops and was told firmly, ‘If you want to eat dead animal, you will have to make another fire over there’. Feeling abashed, but not wanting to appear weak, I complied and before long, lean vegetarian children were crowding hungrily around my sausage sizzle. That day, we found a middle path. The meat was snaffled and I had grilled vegetables. Delicious. Harking back to ‘65, that same Professor Hensley lobbed another cultural-nutritional hand grenade. He said, ‘if the Aboriginal people in the Sydney region had eaten as much meat as we do, they would have needed a hunting ground the size of NSW’. Change comes slowly, but when it does, it can happen fast. Nutrition and health have been on the slow boil for a long time. Now we can’t get enough. Brain-gut microbiome, fasting, gluten, lacto, omegas, paleo, phytosterols, polyphenols, probiotics, turmeric and vitamins ingredients of buzz in a pressure cooker of confusion. Grandma, it’s time to rollover.

book review Robin Osborne

He spent ten years living in isolation in a rainforest camp where he slept on beds of leaves, caught and cooked wildlife - bats, lizards, snakes, even earthworms

Out of the Forest Gregory P. Smith, William Heinemann 334pp $34.99

he road to homelessness can begin with various factors, including childhood neglect and abuse, poor education, rental unaffordability and ill health. Gregory Smith knows this all too well, having grown up in a dysfunctional and violent family, been abused in a Catholic orphanage, at high school, juvenile detention centres and jails, and becoming homeless for years. Dr Smith, as the PhD graduate from Southern Cross University (SCU) is now known serves on the board of Anglicare North Coast, is an ambassador for St Vincent de Paul Society’s homeless centre in Tweed Heads, a 34

founder member of VoiceUp that helps adult survivors of childhood violence, and advocates for the rights of Forgotten Australians who were taken into ‘care’. Gregory Smith was unambiguously homeless for more than a decade, much of it in a makeshift camp in the Mullumbimby hinterland, a journey that started with violent parents who said he’d never make anything of himself. Whatever self-confidence was left took a further tumble when, as a ward of the state, he received a psychiatric diagnosis of being a sociopath. After youthful runaways and recaptures (and beatings) by police, Gregory took to the road, finding itinerant work, abusing alcohol and drugs, provoking fights, failing in relationships. Mostly he managed to stay one step ahead of the law.

In 1989, sick of the urban life that offered nothing but anguish, he went bush, spending the next ten years living in isolation in a rainforest camp where he slept on beds of leaves, caught and cooked wildlife - bats, lizards, snakes, even earthworms - before going vegetarian. He continued to numb himself with homegrown cannabis, home-made beer and local gold-top mushrooms. On occasional walking trips to town Gregory would hang out in Byron Bay and Mullumbimby parks, trade dope, and return home with such essentials as rice, cask wine, Tally-Ho papers and The Byron Shire Echo, valued for practical reasons rather than its journalism. “I painstakingly swaddled the matches in strips torn from the Echo and then wrapped the bundle in a piece of cloth,” he recounts in his memoir “Out of the Forest” (co-authored with journalist Craig Henderson). The extraordinary tale is attracting attention from around the world. “Later on I’d use the Echo to store perishable food, marijuana, magic mushrooms or anything else I wanted to keep for more

a publication of North Coast Primary Health Network

than a day or two.” Gregory spent 10 years as a forest recluse, enjoying “the steep, green farmland of lushly carpeted fields…skirted by neat crops of sugarcane and rambling rainforests.” He emerged after an encounter with what he can only call “aliens” who came for him when he was “in a pretty bad way.” Down at Tweed Hospital he weighed in at just 41kg and “my mental state was frightfully feeble”. With great trepidation, he enrolled in a computer program at TAFE, going on to do a tertiary preparation course, followed by a Bachelor degree in Social Sciences at SCU (Honours 1st Class), and later a doctorate focusing on the later-life experiences of children, including himself, who had been placed in out-of-home care before 1974. “My central finding was that the majority of care leavers had significant difficulties in developing relationships in their families, in their communities and in society more broadly,” he writes. “I found that more than thirty per cent of my participants had serious drug and alcohol problems at some point in their lives, just as I had. This is significantly higher than that among the general population.” Dr Smith has been formally diagnosed with chronic severe PTSD, severe depression and social anxiety. His consulting psychologist says is it likely that he has had these problems since childhood - “For decade upon damaging decade,” as the author observes. “We need so many more services to help homeless people recover their dignity, and much more investment in early interventions like affordable housing, health care, and education,” he said. “Imagine if the $7 billion to be spent on those defence drones was put into preventing people falling through society’s cracks.” healthspeak August 2018

Lifestyle medicine for survivors of cancer

ancer survival is broadly defined as being from the time of the diagnosis to the end of a patient’s life. A more targeted definition is survival from the end of primary treatment to either a recurrence, or if no recurrence until end of life. Between 2009 and 2013, individuals diagnosed with cancer had a 68% chance By Andrew (68% for males and 69% Binns for females) of surviving for 5 years compared to their counterparts in the general Australian population. (1) The cancers that had the largest survival gains were prostate, kidney cancer and non-Hodgkin lymphoma. Since the much heralded ‘war against cancer’ in the early rence, anxiety, depression and 1970s, and the ensuing advances insomnia. in early detection and molecular There are also body image understanding of the biology of concerns such as occurs after cancer there have been a steadily mastectomy. Also erectile dysgrowing number of cancer function is commonly seen with survivors. Lifestyle advice can reduce the men following prostate surgery. Osteoporosis and sarcopenia recurrence of primary cancers, (muscle loss) are sigimprove quality of life nificant risk factors. and prolong the duPain is sometimes ration of survival. A team approach to chronic and For example in encourage a healthy cardiac and breast cancer, lifestyle along with pulmonary a 30 to 40% appropriate specialist complications reduction in care will give the best can occur. survival and quality recurrence rate There is sigof life outcomes for was observed survivors. nificant overlap in women who between the risk followed weight factors for many types management and exerof cancer and those for other cise regularly. (2) chronic diseases. Lifestyle choicAfter active treatment there es such as smoking, unhealthy is a need to detect recurrence eating, inactivity, obesity, alcohol of the primary cancer or the and illicit substance abuse all development of any other types have proven links with chronic of cancer. Also to be monitored disease. are later side effects of primary When it comes to healthy eattreatment, prevention of future ing, tips need to be practical. The cancers and treatment of cobest way is to choose food that is morbidities. As regards late less processed and avoiding ‘junk effects of primary treatment, the food’ high in fats and sugars. stand out concerns for patients are fatigue, ongoing fear or recur- Choosing more traditional food such as found in Mediterranean, August 2018 healthspeak

The Byron Bay Dragon Abreast team out on the water.

Asian, Aboriginal or Nordic diets is beneficial. Limiting drinks with high sugar content, caffeine and alcohol is also helpful. Physical inactivity leads to loss of lean body mass (sarcopenia), increased fat mass particularly around the waist (central and visceral) but it can also infiltrate muscle (marbling). With cancer and its treatment there may be increased osteopenia and osteoporosis, reduced VO2 max (lower fitness level) and increased insulin resistance, leading to impaired sugar metabolism. So what sort of exercise is good for cancer survivors? As with everyone the emphasis should be on aerobic exercise and resistance training. Tailoring the exercise plan for each patient is best done with the aid of input from an exercise physiologist or physiotherapist. Now popular amongst breast cancer survivors is the sport of dragon boat racing, which helps women physically as well as emotionally as they group together in teams. An organisation promoting this activity is called Dragons

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Abreast which has branches in Byron Bay and Coffs Harbour. To address all risk factors GPs are well placed to assist cancer survivors though the Medicare systems for managing patients with chronic disease. A targeted care plan and engagement of appropriate allied health practitioners can make a big difference to quality of life and longevity. So often cancer survivors also have other chronic diseases and a lifestyle medicine approach for their cancer will help manage the co-morbidities. Care plans can also ensure that vitally important cancer specialist follow up is adhered to. A team approach to encourage a healthy lifestyle along with appropriate specialist care will give the best survival and quality of life outcomes for survivors. (1) https://canceraustralia.gov.au/ affected-cancer/what-cancer/canceraustralia-statistics (2) Ibrahim EM, Al-Homaidh A. Physical activity and survival after breast cancer diagnosis:meta-analysis of published studies. Med.Oncol. 2011; 753-765 35

Health&Lifestyle

The downside of horses, skateboards and bicycles W

e have all experienced some type of injury in our lives, be it By Chris minor or more cataIngall strophic. I am talking today about just the physical, not the psychological, the latter an affliction which seems to be of particular concern to certain generations and would take more than 700 words to unravel. Mostly we just soldier on, though with cuts which require a suture, or sprains which require some form of protective splint to enable us to funcner after that first glass of wine years ago! tion. are common causes of burns The other group of injuries is The next step up of course is and cuts. Dangerous place, the what I call RS (repetitive strain, a fracture, with the diagnostic kitchen! or really silly), and these are the trilogy of tenderness, deforMoving vehicles, be ones caused at work and in the mity and loss of function they bicycles, mogym. At least in the workplace pathognomonic. torbikes or cars, you’re getting paid for it, while These are better On a brighter create headlines at the gym it really is self-inflictdocumented, as note, road-related even when a ed. Think lifting heavy weights they roufatalities have pedestrian is repetitively in just the wrong tinely enter dropped from around not involved. way...that’s why the presence the world of 30 per 100,000 Young men of say an exercise physiologist Medicare billpeople in 1970 to just and the elderly in the gymnasium to help you ing or hospital over 5 per 100,000 are over-repreunderstand how you personally attendance. in 2016 sented in the stacan safely get fit is a must. Some accuse us tistics. On a brighter Adults who attend a gym are medicos of a double note, road-related fatalities twice as likely to suffer injuries standard here, and I must have dropped from around 30 to their feet (dropped barbells), admit I have ‘missed’ three frachead (hitting equipment), treadtures in my own children, giving per 100,000 people in 1970 to just over 5 per 100,000 in mill trips and slips, and muscle the ‘soldier on’ advice until 2016, with injuries a strain, compared to someone bothered to perform steady multiplier non-attendees. an X-ray. of 15 over the The workplace For kids, horses and skateI must admit I deaths. Better ones are more boards are often the culprits, have ‘missed’ three cars, better interesting, not infrequently just after fractures in my own roads, and and affect Christmas, when learning children, giving the ‘soldier on’ advice possibly about 12% curves are sharpest. An often until someone better drivers of all workers forgotten injury is a burn, and bothered to perform must be the annually, year again in childhood the tug of a an X-ray reason as car in year out, tablecloth or scalding hot fluid numbers have according to the from the microwave can be increased three-fold Australian Bureau of causal. Advances in insulating during this time, from 4.3 to Statistics. Much has been materials mean we just don’t 13 million vehicles. That means made in recent years of OHS appreciate just how hot that (now WHS) standards, but soup is! For adults, boiling oil in road travel is nearly 20 times safer compared to nearly 50 they don’t always recognise the the kitchen and preparing din-

a publication of North Coast Primary Health Network

niggardly and repetitive causes of injury, part and parcel of the making of the company dollar. How to avoid injury? Well, people who are more physically adventurous are at least twice as likely to be injured as the sessile amongst us, but the latter are over-represented with their bones breaks, usually but not always in their senescence. The fractured neck of femur swings into focus here, with 5% of falls caused by the fracture, rather than causing it, and of course in the other 95% osteoporosis is usually operative. So measured, low impact exercise, like cycling or prescribed resistance training, is the order of the day if you wish to avoid sarcopaenia or osteopaenia in your later years. Staying clear of nicotine (osteoporosis) and alcohol in excess (osteoporosis, sarcopaenia and of course being drunk and silly) are also wise, if you want to stay on the right side of the ledger. And of course, if recovering from an injury, be patient, dear reader. More importantly, be a patient, and do as your doctor or physio tells you. And as a final word, I give you the thespian salute “Break a leg!”

healthspeak August 2018

Health&Lifestyle

Every cancer patient should be prescribed exercise E very four minutes 3. refer patients to an exercise someone in Australia is physiologist or physiodiagnosed with cancer. Only therapist with experience one in 10 of those diagnosed in cancer care. will exercise enough during and after their treatment. But every Why prescribe exercise? one of those patients Cancer patients who exwould benefit from ercise regularly experiexercise. ence fewer and less By Prue Cormie, I’m part of severe side effects Principal Research Australia’s peak from treatments. Fellow in Exercise & Cancer, Australian body representing They also have a Catholic University health professionlower relative risk of als who treat people cancer recurrence and with cancer, the Clinical a lower relative risk of Oncology Society of Australia. dying from their cancer. Recently we joined 25 other If the effects of exercise could cancer organisations to call be encapsulated in a pill, it for exercise to be routinely would be prescribed to every prescribed to all cancer patients. cancer patient worldwide and Our plan is to incorporate viewed as a major breakthrough exercise alongside surgery, in cancer treatment. If we had a chemotherapy and radiotherapy pill called exercise it would be to help counteract the negative demanded by cancer patients, effects of cancer and its treatprescribed by every cancer ment. specialist, and subsidised by government. What are we calling for? Research shows exercise can Historically the advice help cancer patients to cancer patients tolerate aggreswas to rest. We sive treatments, If the effects of now know this minimise the exercise could be encapsulated in a pill, advice may physical deit would be prescribed be harmful clines caused to every cancer to patients, by cancer, patient worldwide and every counteract and viewed as a major person with cancer-related breakthrough in cancer cancer would fatigue, relieve treatment benefit from exermental distress cise medicine. and improve quality Most doctors and nursof life. es agree exercise is beneficial When appropriately prebut don’t routinely prescribe scribed and monitored, exercise exercise as part of their patients’ is safe for people with cancer cancer treatment plan. and the risk of complications is It is our position that all relatively low. health professionals involved in In fact, people with cancer the care of people with cancer who exercise have lower medishould: cal expenses and spend less 1. view and discuss exercise time away from work. as a standard part of the cancer treatment plan What exactly should be 2. recommend people with prescribed? cancer adhere to exercise Exercise specialists can preguidelines scribe exercise in a similar way August 2018 healthspeak

that doctors prescribe medicaHow will patients fill the tions. prescription? These individualised proGetting this much exercise may grams involve specific types of seem out of reach for many exercises, performed at precise people with cancer. But exercise intensities and volumes specialists who have based on a mechaexperience in cancer nism of action care can help. and dosage They’ll design needed to an individual Exercise is safe for counteract program people with cancer and the negative based on can be tailored for the effects of the patient’s individual. Photo Credit: cancer. disease, Exercise Oncology team The how they’ve at Australian Catholic University evidenceresponded to based guidetreatment and lines recommend the anticipated people with cancer be as trajectory of their health physically active as their current status. ability and conditions allow. For Online directories can significant health benefits, they help find accredited exercise should aim for: physiologists and physiothera1. at least 150 minutes of modpists practising nearby. These erate intensity aerobic exerservices are eligible for subsidies cise weekly (such as walking, through Medicare and private jogging, cycling, swimming) health insurance. 2. two to three resistance Or patients can opt for strucexercise sessions each week tured cancer-specific exercise involving moderate to vigormedicine programs such as ous intensity exercises target- EX-MED Cancer, which I lead. ing the major muscle groups Such programs are designed to (such as weight lifting). maximise the safety and effectiveness of exercise medicine for These recommendations should cancer patients. be tailored to the individual’s abilities to minimise the risk of Reprinted with permission from complications and maximise the The Conversation benefits. – www.theconversation.com

a publication of North Coast Primary Health Network

CALL TO PRESCRIBE EXERCISE TO ALL CANCER PATIENTS

C A N C E R O N T H E N O RT H C OA ST

statement by the Clinical Oncology Society of Australia (COSA) that doctors should prescribe particular exercise regimes and refer patients to exercise specialists with experience in cancer care has been endorsed by 25 health organisations. "We're at a point where the level of evidence is really indisputable and withholding exercise from patients is probably harmful," said A/Prof Prue Cormie, lead author of the statement. "If we could turn the benefits of exercise into a pill it would be demanded by patients, prescribed by every cancer specialist and subsidised by government. It would be seen as a major breakthrough in cancer treatment." COSA recommends that GPs refer cancer patients to an exercise physiologist or physiotherapist to manage their exercise regimen. The COSA statement also said that most people with cancer didn’t meet exercise recommendations. Their recommended level of exercise is: At least 150 minutes of moderate intensity or 75 minutes of vigorousintensity aerobic exercise (e.g. walking, jogging, cycling, swimming) each week; and Two to three resistance exercise (ie lifting weights) sessions each week involving moderate to vigorous-intensity exercises targeting the major muscle groups. Port Macquarie physiotherapist and exercise physiologist Leah Burton from Phyx You has undergone further specialised training to work with cancer patients and said there are many proven benefits that flow from them taking regular exercise. “We know that up to 90% of cancer patients may get cancer-related fatigue and exercise has a really positive effect on managing that fatigue. Some of the improvements include preservation or increases in muscle mass and strength, fitness, flexibility and range of movement. “It’s also great for body image, selfesteem and mood which is a common struggle especially in female cancer patients and exercise also reduces many symptoms and side effects that come with treatment.

H E A LT H S P E A K

AU G U ST 2 01 8

Leah Burton with brain cancer patient Tanisha Walker

WE’VE GONE AWAY FROM TELLING PEOPLE TO REST. EVEN ON THOSE BAD LOW-ENERGY DAYS, WE STILL ENCOURAGE PATIENTS TO DO SOME FORM OF EXERCISE Leah has also noticed significant advantages post treatment. “Cancer-related fatigue can continue long after treatment and exercise can have a huge positive effect, which in turn has a big impact on an individual’s quality of life,” she said. Leah pointed out that research also shows that exercise reduces: Duration of hospitalisations Depression and anxiety Psychological and emotional stress Risk of other co-morbidities Recurrence of cancer Risk of cancer deaths Leah said that years ago it wasn’t known if exercise was safe for people going through treatment and post cancer treat-

ment. Whereas now all the emerging research shows it’s safe for most cancer patients. “We’ve gone away from telling people to rest. Even on those bad low-energy days, we still encourage patients to do some form of exercise as it will have a positive impact on their wellbeing.” From page 3

the Heart should be endorsed on health grounds alone. These are well worth reading: https://croakey.org/5-reasons-toendorse-the-uluru-statement-fromthe-heart-on-health-grounds-alone/ Overall I was enlightened by this conference and have a better understanding of the challenges before us. The self-determination message from speakers was loud and clear. There is so much we non-Indigenous health professionals can do to become more culturally aware of the serious plight of our Indigenous community and support them both with our clinical skills and politically.

From page 5

Sunita Bala and Aboriginal artist Michael Philp became part of the groups, facilitating participants to create post-card sized artworks around the topics discussed. “The art-based groups were run at Rekindling the Spirit, Namatjira Haven and Bunjum Corporation between March and May 2018 and were a revelation, the opposite of the earlier groups. Participants found them a joy to participate in; they were a pleasure to run and participants had some major insights about themselves and their world,” said Natalie. In fact after working for many years with Aboriginal people, James and Natalie consider art-based CFT to be the most promising approach to enhancing social and emotional wellbeing in Aboriginal clients they’ve been involved with. “We started the four-hour long groups with a 20-minute discussion about the topic of the day, then created artwork around that topic for the next 2-3 hours, then finished up with a reflective discussion about our artwork,” said Natalie. For instance, the group’s first session focused on creating a sense of safeness personally and in the group – “that is, whatever safeness meant to them”, noted James; “for instance the memory of being in the presence of a loving grandmother, or the sense of calm from being in place of special significance”. Participants then represented in their artwork what safeness meant to them. One of the key concepts in CFT is the

Having worked in this space for 10 years, this new art-based approach to CFT is just gold Natalie Roxburgh

James Bennett- Levy

idea of three emotional systems: the threat system, the drive system and the soothing system. “You aim to build the soothing system, which in people who’ve been traumatised is pretty under-functioning. If you guild a soothing system that mitigates the threat system and means the drive system will be going in positive rather than negative directions,” James said. Participants were provided with lots of material to create postcard collages along with pastels and paints. James said people who would otherwise baulk at talking about themselves in a group, opened up spontane-

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ously while creating their art. Incidental conversation came easily and the atmosphere was warm and non-threatening. Interestingly, James and Natalie also took part in the art component of the sessions which helped promote the sense of safeness among those taking part. James is excited about the success of these sessions. “We’ve not had one negative experience, and only positive comments from everyone. During this pilot we went from running groups that were pretty difficult for some of the participants to running the best and most fun groups, it was just great. Having worked in this space for 10 years, this new art-based approach to CFT is just gold.”

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