HealthSpeak Spring 2014

ISSUE 9 spring 2014

HealthSpeak A publication of North Coast NSW Medicare Local

Kaizen Re-launch Quality Improvement Program for general practice page 5

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Emergency workshops

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Colocation pilots

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Shared Medical Appointments

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Substance misuse training

A voice for North Coast health care Janet Grist Head Office Suite 6 85 Tamar Street Ballina 2478 Ph: 6618 5400 CEO: Vahid Saberi Email: enquiries@ncml.org.au Hastings Macleay 53 Lord Street Port Macquarie 2444 Ph: 6583 3600 Cnr Forth and Yaelwood Streets Kempsey 2440 Southern Region Manager: Donna Burns Email: dburns@ncml.org.au

Editor

This Spring issue of HealthSpeak magazine is the ninth

Northern Rivers Tarmons House 20 Dalley Street Lismore 2480 Ph: 6622 4453 Northern Region Manager: Chris Clark Email: cclark@ncml.org.au Tweed Valley Unit 4, 8 Corporation Circuit Tweed Heads South 2486 Ph: (07) 5523 5501 Northern Region Manager: Chris Clark Email: cclark@ncml.org.au

Contacts Editor: Janet Grist Ph: 6622 4453 Email: media@ncml.org.au Clinical Editor: Andrew Binns Email: abinns@gmc.net.au Design and illustrations: Dougal Binns – Graphiti Design Studio Email: dougal@gdstudio.com.au Display and classified advertising at attractive rates

HealthSpeak is published four times a year by North Coast NSW Medicare Local Ltd. Articles appearing in HealthSpeak do not necessarily reflect the views of the NCML. The NCML 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 2014 North Coast NSW Medicare Local Ltd Magazine designed by Graphiti Design Studio Printed by Quality Plus Printers of Ballina

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word about the good work being done by health workers and others in health and community organisations.

Thanks for reading and supporting HealthSpeak and submitting articles and ideas. Our online readership is in the thousands with 1500 hard copies printed.

With your support, HealthSpeak will continue to grow.

An idea whose time has come

Mid North Coast Suite 2, Level 1, 92 Harbour Drive Coffs Harbour 2450 Ph: 6651 5774 Southern Region Manager: Donna Burns Email: dburns@ncml.org.au

we’ve produced and since it began in September 2012, it’s been exciting to see the many links NCML has forged with health care providers and the broader community.

As well as showcasing the various programs and services that NCML runs in the region, around half the magazine is regularly dedicated to spreading the

Vahid Saberi Chief Executive Officer

It was Victor Hugo who said, “no one can stand in the way of an idea whose time has come”. This seems to be true of integrated care. Integrated care is now the international movement in health care delivery. While it is called by different names in different places, there is, nevertheless, the recognition that unless we reduce care fragmentation we will not improve patient experience and outcomes or increase the efficiency to meet demands.

For the first time, the NSW Health System (NSW Minister for Health, Hon Gillian Skinner, should get much credit for this) has put real money - $120 million over four years - to fund care integration across sectors, especially acute and primary health care.

The real challenge now is to turn good intentions and ideas into real change on the ground.

How do we achieve this transformational change? Over the past two years we at the Medicare Local have focused our minds and energy to learning about, and achieving integration. There is much that needs to be done in this space - I will focus on two

key issues.

We have learnt that at the front and centre of achieving change is input from, and ownership of the change, by clinicians and those working on the ground. I recall a few years ago I visited a country with a serious and determined agenda of improving the health outcomes of its population. Given the high rates of home births and the associated adverse events, the Government, as a means of encouraging safer hospital births, initiated a campaign of paying a financial incentive to those who birthed at their local hospital.

This campaign was successful in doubling the rates of hospital births, and was disastrous in that it brought the hospital infrastructure to its knees with two patients to a bed, beds in corridors, and tragic infection rates. This was a well-intended, badly designed and implemented strategy with terrible consequences.

The outcomes of that strategy could have been different had there been appropriate consultation with the clinicians and those working on the ground. Shared vision and co-designing is crucial to avoid destabilising the system.

Any service redesign that does not enable care providers to be at the forefront of change and transformation is destined to fail.

The example above highlights the importance of consultation about care integration, especially with primary health clinicians.

As the vision of the future is for

more care to be provided outside hospitals, consultation with primary health care providers is paramount as the change most obviously impacts on their work.

In addition to listening to clinicians, we have learnt that hearing the voice of the community is critical in the change process. We all appreciate that in marketing a product the satisfaction and feedback of those who use the product is central. Why is it then that we struggle with the concept that the health care system has to be shaped by both those who use it and those who deliver it?

This is not a hard concept to grasp, but in practice it is hard to make happen. Our experience is that listening is not sufficient.

True meaningful engagement requires collaboration, partnership and joint decision making – a reorientation about how we think and work. To be most effective, community and patient engagement has to be a process, an ongoing conversation, rather than an event. It needs ongoing commitment and resources.

The other lesson we have learned is in regard to the softer aspects of change. Creating an environment open to transformational change, innovation and collaboration is built on the bedrock of mutual trust and respect.

Without trust and goodwill we are building castles in the sand and the rain and wind, inevitable parts of implementation and growth, will wash away that change.

HealthSpeak is kindly supported by HealthSpeak

A publication of North Coast Medicare Local

spring 2014

Best Practice for End of Life Care Andrew Binns reflects on the achievements of the MyChoice program after three years’ operating in general practice.

In the past, Palliative Care (PC) has tended to focus on terminal cancer, but as general practitioners well know, patients with other non-malignant chronic diseases also need a primary care team approach to support the complex needs of providing terminal care. In 2010/2011 the Northern Rivers GP Network was commissioned to undertake a 12-month Rural Palliative Care Project aimed at addressing best practice end of life care for sufferers of a chronic disease.

Badged ‘MyChoice’, it was aimed at developing a framework for managing end of life care. The intention was to give patients the opportunity to articulate their choices and enhance the control they have over their terminal care. The project officer (PC Clinical Nurse Consultant Kate Stirling) led the way in developing this document in consultation with local GPs and the NCAHS PC team based at St Vincent’s Private Hospital Lismore.

An excellent resource manual (on the NCML website) was the result. Step 1 described a process for initially identifying the clinical indicators as to who should be classified as a PC patient.

They are then registered as such in the practice medical record system. An Advanced Care Directive (ACD) is recommended, for which a MyChoice template is provided. This is very clear and easy to follow - unlike many others available.

Step 2 is to assess the patient and carer needs; this is a questionnaire to be filled out by the patient, with carer input as needed.

Step 3 is to develop a GP management plan and/or a team care arrangement with appropriate referrals made to the local Specialist Palliative Care Service (SPCS) when needed. Practice

nurses can play a major role in developing these arrangements.

To have a framework to use is very helpful for both GPs and the team they work with.

These three steps were based on the Gold Standards Framework© developed in the UK more than a decade ago. It is a systematic approach to providing best practice for end of life care, regardless of diagnosis. It has had strong support from GPs in the UK, and with some adaptations the MyChoice project is well suited to practices here. Chronic care management support systems through Medicare help fund the implementation of these steps.

It is estimated that currently two-thirds of patients whose death is expected are managed solely by primary care providers.

The remaining one-third may either require occasional input from a SPCS or have complex needs and require ongoing SPCS involvement. (Palliative Care Australia 2005. A Guide to Palliative Care Service Development: A population based approach).

End of life care requires a team approach. Those who choose to die at home need to have a GP prepared to do home visits.

During 2013, North Coast GP Training (NCGPT), the Northern NSW LHD and the North Coast NSW Medicare Local (NCML) collaborated in a pilot scheme to determine whether providing a GP registrar to assist GPs in looking after their end of life patients under the clinical supervision of the PC Staff Specialist (currently Dr Ken Marr), could make a difference to: 1. The proportion of patients who fulfill their wish to die at home when this is manageable.

2. The number of days admitted to hospital between referral to the service and death.

3. The number of hospi-

HealthSpeak A publication of North Coast Medicare Local

spring 2014

tal admissions between referral to the service and death.

4 The number of completed Advance Care Directives The initial pilot was funded by the NNSW LHD and NCML, with support for research from Australian General Practice Training and NCGPT. The role of the GP Registrar PC facilitator was to initiate advance care planning by conducting an initial patient evaluation and subsequently providing ongoing home visits in liaison with the palliative care team at the request of the patient’s GP. It also focused on increased support for clients in the home setting during the terminal phase by providing a formalised end of life planning service and regular medical review in the terminal phase.

Two GP registrars with an interest and training in palliative care were recruited to the role as part of their training.

GPs in a specific geographical area were invited to refer appropriate palliative patients to this service, while retaining the role of the principal treating doctor.

Data collected was compared to data collected in the same time period from another geographical area in the Richmond catchment area.

Anecdotal reports from referring GPs, patients and carers were overwhelmingly positive and the interim data on home death rates, hospital admissions and bed days and ACD completion rates have been significantly better in the group receiving the additional service. For this reason the project has been extended for another year.

It is well known that end of

Opinion Andrew Binns

life care in hospitals can result in inappropriate, futile and costly clinical intervention. To have a framework to manage such patients according to their wishes, whether at home or hospital with appropriate GP and PC team support, is good clinical practice. At the same time there are potentially significant cost savings for the health system.

It is estimated that currently two-thirds of patients whose death is expected are managed solely by primary care providers 3

Emergency situation workshops North Coast Medicare Local (NCML) has had an overwhelming response from general practice staff wanting to attend its Emergency Management workshops. These five, three-hour workshops give staff the skills to respond to various medical emergencies in medical clinics – airway, breathing, circulation, cardiovascular and disability.

The brainchild of NCML Chair Dr Tony Lembke, these free workshops being held initially in Lismore, Murwillumbah and Grafton, are offering a set of valuable team-based skills to manage such emergencies. They also attract generous CPD points.

Thanks to all the general practice staff who are attending these evenings - the first workshop was on August 12 - we couldn’t hold them without your enthusiasm for learning. Due to the high response rate (three times oversubscribed in Lismore) it’s anticipated the workshops will be run again in Lismore and

lation educators Bobbie Youngberry and Sharene Pascoe.

Thanks also to Drs Richard Deaker, Paul Earner and Anne Drinkwater for reviewing the course outline.

Evaluation comments were very positive. Some from the first workshop included:

Workshop participants take part in an exercise involving a scenario where a child gets a lolly stuck in his airway.

Murwillumbah in late 2014 or early 2015.

These Emergency Management workshops are the result of a partnership between the University Centre for Rural Health (UCRH) in Lismore, North Coast GP Training and NCML. They are being held in the UCRH’s Simulation Centres.

They allow 20 participants to practice emergency skills and work together as a team while undertaking immersive scenarios which replicate emergencies that occur in general practice environments.

The curriculum was developed

by UCRH and the workshops are delivered by accredited simu-

Interested in working with the disadvantaged?

The former Winsome Hotel houses Lismore Soup Kitchen and clinic.

North Coast Medicare Local (NCML) is calling for expressions of interest from GPs and nurses located in the Northern Rivers region to provide medical services at the Winsome Health Outreach Clinic in Lismore.

Since April 2013, NCML in partnership with NNSWLHD, St. Vincent de Paul and the Winsome, has been providing an outreach health service 4

on-site at The Winsome, a large facility owned and run by the Lismore Soup Kitchen Inc. The Winsome, predominately self-funded and reliant on a volunteer workforce, provides valuable support for some of the community’s most vulnerable people. It provides accommodation for men and daily meals for those in need.

Every Wednesday morning, an Outreach Health clinic is

held on-site, providing free GP and clinical nursing services to clientele of The Winsome.

Dr Charles Hew of Goonellabah Medical Centre and Dr James Boyd from Jullums (Lismore Aboriginal Medical Service) alternate weekly in providing GP services. NNSWLHD provides a community nurse.

The Clinic is well-established and 77 individual patients have accessed the clinic over the past 12 months, with more than 400 occasions of service during this period.

In the next six months, NCML and Vinnie’s are working together to construct a purpose built clinic on the ground floor of The Winsome, comprising a doctor’s room, a nurse’s room and a reception/waiting area.

NCML needs more health professionals – including GPs and nurses- to meet the clinic’s demands and to join our multidisciplinary team on a contract basis. If you are interested, contact Program Manager Monika Wheeler on 6622 4453 or via email: mwheeler@ncml.org.au HealthSpeak

“Excellent, gave us the confidence to manage emergency situations.”

“Light-hearted but very informative and hands-on.”

“Excellent, looking forward to the next one.”

Dates are being drawn up for Emergency Management Workshops in Coffs Harbour and Port Macquarie.

There is also the potential to use the UCRH mobile simulation bus to run courses at Kempsey, depending on the availability of educators.

Briefs

Detergents and infertility Two ingredients found in household detergents caused reproductive decline in mice, according to a new study published in Reproductive Technology, prompting concerns about the effect of these ingredients on humans.

In this study at the Virginia-Maryland College of Veterinary Medicine, researchers found that two chemicals - alkyl dimethyl benzalkonium chloride and didecyl dimethylammonium chloride - had a similar effect in mice.

These chemicals are present in an abundance of household products such as household cleaners, disinfectants, hand sanitisers and fabric softeners, but the effect they have on humans is a mystery, with more research needed on the subject.

A publication of North Coast Medicare Local

spring 2014

Kaizen Mark Two is off and running After a two-year hiatus, last month North Coast Medicare Local staff were delighted to re-launch the Kaizen Quality Improvement Program for general practice staff in August.

Evening Kaizen meetings were held in Tweed, Ballina and Lismore looking at the Coordinated Veterans Care Program and Telemonitoring. More are planned in southern North Coast towns.

HealthSpeak attended the Lismore gathering where NCML Chair Dr Tony Lembke welcomed around 22 people - GPs, practice nurses, practice managers and North Coast Medicare Local staff - to the rejuvenated Kaizen meeting.

He said the North Coast Medicare Local Board and senior management were strongly supportive of Kaizen and the program would be resourced appropriately to ensure its success.

Tony explained the aims of Kaizen, a continuous Quality Improvement program, which he set up about five years ago.

“Kaizen is not just a meeting, it’s a group of people who get together to improve health, to improve the way they deliver their services to benefit patients.

The program has three aims – to improve our patients’ health outcomes; to make working in general practice a better experi-

Chiron Weber talking about Quality Improvement Tools.

ence for patients and staff and to make all our lives easier; and to improve our practice bottom lines.”

Tony said Kaizen was about bringing about quality improvements in general practice in a sustainable way.

“We’ll be sharing our ideas generously and stealing ideas and resources shamelessly from others to improve our practices,” he said.

North Coast Medicare Local has also recently signed a contract with The Improvement Foundation.

The Foundation will provide Kaizen participants with their own portal – QI Connect – which will allow for group projects, make submitting data easier and help with developing

resources for particular health topics.

Kaizen meetings will be held monthly at different venues so that participants can visit other medical centres to see first hand their resources and how they operate.

In addition, Kaizen participants will be able to meet online in the new practitioner network portal set up on NCML’s Healthy North Coast website and share valuable resources there. (www.healthynorthcoast. org.au) At the first round of Kaizen meetings, Mullumbimby Medical Centre practice manager Chiron Weber gave a presentation on Quality Improvement Tools and a model for general practice; practice nurse Donna

HealthPathways growing quickly

An initiative of North Coast Medicare Local and the local health districts, HealthPathways is an online portal set up to allow health practitioners to assess and manage a wide range of medical conditions, with pathways for easy referral to local specialists and allied health practitioners.

There are now 30 localised HealthPathways published and available online. These have been put together in work-

groups made up of GPs, specialists, allied health practitioners and nurses. Some recently published HealthPathways topics include Abnormal Liver Function Tests, Tetanus Prone Wound Management, Pertussis Vaccine for Pregnant Women and Enuresis in Children.

A further 79 HealthPathways are being developed. Since HealthPathways went live in March this year, the most popular five medical conditions

HealthSpeak A publication of North Coast Medicare Local

spring 2014

accessed online have been: Persistent non-cancer pain Gastroenteritis in children Opioid use in persistent pain Improving milk supply Hospital in the home Through re-thinking how a particular medical condition

Practice Nurse Donna Gibson

Gibson from Alstonville Medical Clinic talked about her experience running the Coordinated Veterans Care Program; and Dr David Guest from Goonellabah Medical Centre gave a presentation on Telemonitoring which really got people talking about how they were managing this technology.

To find out more phone NCML staff: Karen Wilson on 07 5523 5500 re Tweed meetings; Casey Guthrie on 6622 4453 in the Northern Rivers , Jenny Morgan in Coffs Harbour on 6659 1800 and Noni Kubowicz in Port Macquarie on 6583 3600.

is managed locally, groups of clinicians and health service managers are leading health system reform piece by piece.

HealthPathways is expected to lead to better care in the GP setting, better access to specialist care, more appropriate use of allied health care, and better patient experiences.

The HealthPathways portal can be found at: http://manc. healthpathways.org.au Please contact Tracy Baker at tbaker@ncml.org.au for the password.

If you would like to be involved in a work group or put forward a pathway to be localised, contact Fiona Ryan, Project Officer, Health Pathways at fryan@ncml.org.au or phone her on 6583 3600.

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Soup kitchen clinic meeting a need Since the medical clinic established by North Coast Medicare Local opened at St Thomas’s Soup Kitchen in Port Macquarie in late March, GP Karen Counter has seen more than 100 patients.

The one day a week clinic is staffed by Karen and NCML Project Officer Annie Orenshaw, who works as receptionist to the GP. Around six patients are seen each week, although this number is increasing.

Annie Orenshaw said the clinic has been embraced by both the soup kitchen diners and the Anglican Church volunteers who run it.

“People really appreciate that the clinic is there and the patients really love Dr Karen’s care,” she said.

But Annie told HealthSpeak that the clinic also presented special challenges.

The GP clinic at St Thomas’s Anglican Church hall in Port Macquarie operates each Wednesday when the church’s soup kitchen is open

“Because most patients may not have seen a doctor in some time, and present with complex needs and chronic conditions, Karen’s consultations are often longer than normal. And even though she might make a follow up appointment for a patient, they don’t always turn up or follow through with pathology tests.”

Annie said working at the clinic has been a steep learning curve,

but she’s found that the best icebreaker is to sit down with soup kitchen clients and share a bowl of soup with them. That way you can earn their trust and they start to respond to you, she said.

North Coast Medicare Local’s other GP clinics for the disadvantaged in Tweed Heads and Lismore are operating well. A clinic in Coffs Harbour is still in the pipeline.

NCML hosts Reconciliation Week events North Coast Medicare Local’s Closing the Gap team hosted two events to mark National Reconciliation Week in Coffs Harbour in late May. National Reconciliation Week is celebrated across Australia each year between 27 May and 3 June. The dates commemorate two significant milestones in the reconciliation journey—the anniversaries of the successful 1967 referendum and the High Court Mabo decision.

The week is a time for all Australians to learn about our shared histories, cultures and achievements and to explore how each of us can join the national reconciliation effort.

NCML hosted a community event in the Coffs Harbour Botanic Gardens with guest speakers on May 28, with more than 40 people gathering to support reconciliation.

NCML’s Closing the Gap Outreach Worker Terry Donovan said the outdoor event featured guest speakers and Aboriginal people were invited to get up and tell their stories. A morning tea was also held at the North Coast Medicare Local office in Coffs Harbour.

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Ken Craig junior, from the local Reconciliation Australia committee speaking to the Reconciliation Week gathering in Coffs Harbour Botanic Gardens. NCML’s Terry Donovan is on the right.

Local didgeridoo player David Carriage helped open the event.

HealthSpeak

Oral health forum Over three days in late May, more than 100 oral health care providers gathered in Port Macquarie, Coffs Harbour and Byron Bay, for Oral Health Promotion Forums.

North Coast Medicare Local has been facilitating quarterly meetings for oral health opinion leaders in our footprint. These individuals are staff of the two Local Health Districts and private dentists well known in their communities for their work in oral health. They get together quarterly and the Forum grew out of these meetings as well as the idea of regular educational evenings.

The Forum’s keynote speaker was Professor Anthony Blinkhorn from the University of Sydney. Public and Private dentists, oral therapists and hygienists were impressed by Prof Blinkhorn’s enthusiasm for disease prevention in oral health.

He spoke of the importance of working with other professions, and in particular made mention of his work with midwives and members of Aboriginal communities.

He explained the importance of working with midwives by pointing out that research shows oral hygiene improves in toddlers and young children if their mother encourages and demonstrates good mouth hygiene.

Many at the forum expressed a desire to network and work further with other health professionals to analyse and address health needs in a more holistic way.

Prof Blinkhorn also spoke of the importance of health literacy and working to ensure community members understand the brochures and messages presented to them.

In future gatherings, the oral health opinion leaders will discuss how to harness this enthusiasm to work with other disciplines in a holistic manner and how to provide spaces for multidisciplinary networking and collaboration.

A publication of North Coast Medicare Local

spring 2014

Compassion fatigue project wins The PITCH The latest round of North Coast Medicare Local’s PITCH (Practical Ideas to Improve Healthcare) was held at Rydges in Port Macquarie in late July.

The topic of this round was Improving Community and Stakeholder Participation in Healthcare. A total of 13 PITCH entries were submitted with three finalists chosen.

At the PITCH evening, three health professionals made their PITCHes – Samantha Cox of North Coast Nurses Pty Ltd talked about her idea for a GP Management System – a system of care that coordinates and unites community and stakeholder participation in residential aged care facilities.

Dr Harriet Playle made her presentation via a pre-prepared video.

Her PITCH was a community project aimed at the rejuvenation and sustainability of the wellbeing of local health care workers.

And Louise Williams of Coffs Coast Nutrition presented via pre-prepared video her PITCH on Community Nutrition for Older People through nutritionists and dietitians making home visits to older folks.

All the PITCHes generated interesting discussions among those present and after a difficult period coming to a decision, the judges pronounced Dr Playle’s

PITCH the winner of the round.

North Coast Medicare Local will work with her to bring her ideas to fruition.

Dr Playle’s suggestions to help prevent burnout and compassion fatigue and rejuvenate local health workers included ideas such as a Fitness Passport, Compassion Fatigue Awareness workshops, an Annual Health Workers award event, and improved access to clinical and peer support and supervision of health professionals.

The following morning, the Copernican Inversion Series breakfast event was held at Rydges with speakers Samantha Cox of North Coast Nurses Pty Ltd talking about her PITCH, North Coast Medicare Local’s Jenn Melsness speaking about the New Access Program and Trish Davis, Health Promotion Coordinator with Mid North Coast Local Health District talking about the Quit for New Life program.

Thanks to the PITCH judging panel – Dr David Gregory, GP, Port Macquarie, Denise Santos, Director of Care, Garden Village, Port Macquarie and Jodie Kennett, dietitian and diabetic educator at JK Healthcare in Port Macquarie.

And congratulations to all those who took part in this round of the PITCH and particularly to the three finalists, and this round’s winner, Dr Harriet Playle.

The morning after the PITCH, NCML held its CIS Breakfast Event at Rydges. Pictured from left: Rosemary Grieve (Port GP Super Clinic), Chris Barratt (NCML), Dr Paul Webster (Webster Medical Centre), Jenn Melsness (NCML), Trish Davis (MNCLHD), Donna Burns (NCML), and Noni Kubowicz (NCML)

Promote your health event through NCML As a result of the large number of requests for North Coast Medicare Local to help promote health events in our region, we have set up a ‘do it To promote your event, simply go to yourself’ system so that organisers the Healthy North Coast website: can post events on our Healthy North healthynorthcoast.org.au/dashboard/ Coast website. signup/ Both events for health practitioners and events for community members Once you register, you can post event information quickly and easily. may be posted.

SNP Collection Centres Locator App now available for iPhone and iPad With our new App, it’s now easier than ever to locate Sullivan Nicolaides Pathology collection centres.

• using a built-in GPS feature and the device’s current location, surrounding SNP collection centres are displayed • filter for opening days and procedural tests to find the most conveniently located SNP collection centre Built in GPS locates nearest collection centre

Locate centres for procedural tests

www.snp.com.au HealthSpeak A publication of North Coast Medicare Local

spring 2014

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Co-locating community health into general practice North Coast Medicare Local, in partnership with the Northern NSW Local Health District (NNSWLHD) and the Mid North Coast Local Health District (MNCLHD), is running a pilot to explore ways of improving the care of patients receiving community and allied health services – by co-locating these health care professionals within general practice.

Eight general practices in the Northern region and three on the Mid North Coast are involved in the project, hosting the services of clinicians from their local health district in their practice.

Services being co-located include a renal nurse practitioner and two chronic care nurse practitioners in the North and a specialist respiratory nurse and an asthma educator in the Mid North Coast region.

Clinics are held at each of the participating practices, providing patients an opportunity to access allied health services from their ‘medical home’.

It is hoped that the colocation of these services will lead to improved integration and efficiency of care for patients with chronic disease through increased communication, record sharing, and skills transfer between treating health practitioners. It’s also envisaged the program will improve the patient experience by receiving multidisciplinary care under one roof.

The project is being evaluated by researchers from the Southern Cross University and findings will be presented at the second World Conference on Integrated care in 2015.

Mid North Coast The Subbiah Family Practice in Port Macquarie was the first to commence with the Colocation project. The first clinic with respiratory educator Maree Kennedy, from Hastings Community Health Centre, was held in May this year.

Maree now conducts two clinics a month, working closely with Dr Nandini Subbiah to 8

Anne-Maree Cheffins, Chronic Disease and Rural Emergency Nurse Practitioner and Renal Nurse Practitioner Graeme Turner learning to use the PENCAT tool.

From left, Kerry Gardiner, practice admin; Maree Kennedy RN, respiratory educator; and Dr Nandini Subbiah GP, from Subbiah Family Practice in Port Macquarie are taking part in the Co-location pilot.

provide care for her patients with chronic respiratory disease.

The pilot has enabled patients from the practice to access Maree’s services in the familiar environment of their ‘medical home’ rather than having to access the services at community health.

Maree mainly sees COPD and asthma patients and says having Dr Subbiah close by is convenient both for her and her patients.

“If I’m unsure of something or have concerns about medications, I can get the GP in to look at the patient straight away. She can then write a prescription for a change of dose or medication and if tests are required, the patient doesn’t need to come back

to see the doctor, she can write out the referral immediately,” Maree told HealthSpeak.

Northern NSW The Goonellabah Medical Centre (GMC) is one of the general practices taking part in the pilot in the Northern region with Dr David Guest taking a lead role.

The Colocation project has provided David with a sharp focus for his two passions – technology and collaboration, bridging the gap between primary and secondary care.

Those involved in the pilot at GMC are Dr Guest, the practice manager, the chronic disease practice nurse, the HealthSpeak

practice’s IT specialist and two clinicians employed by NNSWLHD, Anne-Maree Cheffins, Chronic Disease and Rural Emergency Nurse Practitioner; Renal Nurse Practitioner Graeme Turner; and NCML pilot coordinator Bernadette Carter.

A system is being set up to identify patients who would benefit from the pilot approach and draw up health care management plans for them.

Additionally, David’s highly collaborative approach to integrating the clinicians into the operations of the practice and the pilot includes an email communication group he has set up.

David told HealthSpeak that another challenge of the pilot was in bringing two different cultures and approaches together successfully.

“Every general practice has a different way of operating and will naturally be different to the state-run health system, but it’s all about communicating, and it’s working,” he said.

At Goonellabah Medical the chronic disease nurse practitioners consult with the patient and then David comes in at the end of the session where it becomes a three-way communication. In this way, clinicians can learn from each other and work together for the benefit of the patient. It’s also time efficient.

Many chronic disease patients are living with multiple conditions and their presentations can be complex. With this team approach, the patient’s care is coordinated and the necessary referrals or tests organised on the spot.

David said that with an ageing population chronic disease was an increasing burden on the community and an increasing issue for general practices.

“The importance of good chronic disease management is recognised by the Federal government with its decision to preserve the Medicare rebates for chronic disease item numbers while slashing those for acute illness,” he said.

The pilot will also be run in an Aboriginal Medical Service and a solo general practice.

A publication of North Coast Medicare Local

spring 2014

Professional Speed Dating for GPs and Specialists

By Noni Kubowicz NCML PAL, Hastings Macleay Branch “The best event any Medicare Local has put on since they began!”

“Great idea!”, “ML should do more events like this!”, “It was good fun!”

From left: Dr Colin Thompson, ophthalmologist, Dr Paul Webster, GP and Dr Kristian Prados, cardiologist enjoyed the opportunity to mingle at the informal event.

Musculoskeletal project In partnership with Mid North Coast Local Health District, North Coast Medicare Local (NCML) has received funding from the Agency of Clinical Innovation to implement three models of care involving musculoskeletal conditions, especially into general practice.

The models of care are for acute back pain, refracture prevention and osteoarthritis of the hip/knee.

NCML’s Clinical Advisor, Southern Region, Dr David Gregory said the project gave general practice an opportunity to step up and for the entire health system to act as a whole, rather than in fragmented bits.

The project brings together clinicians of different persuasions - GPs, rheumatologists, physios, orthopods, nurses, dietitians and others. Clinical groups are formed for each topic, look at the evidence around diagnosis and treatment and advise on best practice.

Dr Gregory said he was excited about this innovation opportunity and he said it was fortunate that the lead clinician of one of these groups, The Acute Back Pain group, is Dr Chris Needs, a Port Macquarie rheumatologist.

The Agency for Clinical

Innovation would like to see these musculoskeletal models of care used widely and, in particular, to be managed in primary care/general practice.

“At this stage it is planned to use HealthPathways as the tool to inform how the models of care can work locally. The next step is to design a simple system that connects the different parts of the health system, so that hospital doctors and clinicians, GPs, specialists, physios, dietitians and everyone else can work together,” said Dr Gregory.

“There are some challenges ahead but this type of model is clearly what a primary healthcare organisation should be pursuing,” he added.

HealthPathways is a webbased information portal supporting primary care clinicians to plan patient care through our primary, community and secondary health care systems.

HealthSpeak A publication of North Coast Medicare Local

spring 2014

These are a few of the comments made by some of the 31 attendees of the inaugural Port Macquarie Professional Speed Dating for GPs and Specialists event held in July at Rydges.

Right from the start this NCML event had an excitement surrounding it. Emails in eager response to attend were flying in moments after the invitation went out! For the first time in a long time, invitees were emailing apologies that they could not attend as perhaps they knew they would miss a good fun and beneficial event.

The mood was set…dim lighting, soft sweet music, flickering candles on the tables and waitresses greeting everyone at the door with a welcome drink. A perfect setting for a Speed Dating Evening… Hold it a minute… “This is supposed to be a PROFESSIONAL Speed Dating Event, like a Networking evening” the on

SLEEP CLINIC AYS OPEN D

FREE consultation

site Function Manager was told.

Cue the normal music and the brighter lights. Right. (Glad none of the attendees noticed the Barry White tune in the background)…now on to the professional networking.

After avoiding what could have been an awkward start, the Port Macquarie Professional Speed Dating for GPs and Specialists was a hit. It was the right amount of business mixed with pleasure, with great socialising opportunities at the beginning of the event and professional networking during the ‘speed dating’.

This was accomplished by seating the 15 specialists at individual tables and having the 17 GPs (some in pairs) rotating to a different specialist table every five minutes when the bell rang.

At times the bell had to be rung twice, so wrapped in conversation were the “dates”.

The event was fun and fresh.

It showed that Professional Networking for our providers can be as fun as you want it to be. It all depends on your imagination and willingness to try something new!

This willingness to try something new and the imagination of Kristy Kostalas and coordination efforts of Christine Cox most certainly paid off. Well done ladies and here’s to the next one!

What would you do for

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9

Enthusiasm for First Aid training First Aid in Small Towns, an extension of North Coast Medicare Local’s First Aid in Community program, has made a great start with Bonalbo and Coraki residents receiving their completion certificates for the one-day first aid training.

Fifteen small towns across the North Coast who have been identified to have limited or no existing medical services, especially after hours, are set to be provided with first aid training. The aim of First Aid in Small Towns is to strengthen the capacity of these communities to respond and provide first aid while waiting for ambulances and emergency services to arrive.

The training was enthusiastically received at both Coraki and Bonalbo. Thirty-two Coraki residents took part (in two classes) with 16 in Bonalbo.

It’s pleasing that North Coast Medicare Local will have ongo-

Happy Coraki residents at the end of their first aid training day with trainer Michael Johnston on the left.

ing conversations with several participants who are interested in enhancing the health and wellbeing of their community.

Comments from course participants included: “Thank you for making our community feel cared for - our health has

improved already!”

“This has been a great opportunity to learn these vital skills and to help relieve fear in the community about long waits for ambulances, particularly in a community that couldn’t have afforded this training otherwise.”

NewAccess mental health support So you have been hearing about NewAccess on Facebook and perhaps seen our NewAccess cars driving around town, but you are not quite sure what all the buzz is about.

As you know, one in five Australians has symptoms of low anxiety or depression that can creep up when you least expect it.

NewAccess is an early intervention program run on the North Coast by North Coast Medicare Local to provide accessible, free and quality services for people with depression and anxiety. It’s a beyondblue initiative funded by the Movember Foundation.

The program is for people over 18 and aims to assist people not currently accessing mental health services. The program offers clients up to six free sessions, including an assessment, five sessions and a review. At the first appointment an Access Coach will complete an assessment and develop a program to 10

suit individual needs.

Since NewAccess started on the North Coast this year, more than 250 referrals have been captured with 60% of these men, and people in hard to reach locations.

Access Coaches are trained at Flinders University and the first appointment with an Access Coach is between 45 to 60 minutes, with subsequent sessions from 20 to 30 minutes. People can refer themselves to NewAccess and sessions can take place face to face or over the phone.

If someone you know is dealing with the following situations, then this service could be of benefit:

Work stress or uncertainty; unemployment Change in living arrangements New parent worries; family problems Health concerns Isolation or loneliness Financial worries or instability Coaches are located in major towns across the North Coast as well as in Maclean, Yamba, Kyogle, Kempsey and Nambucca. To take action and get back on track, call 1300 137 934. Alternatively, you can contact an Access Coach online at: beyondblue.org.au/ NewAccessCoach

HealthSpeak

New patient advocacy training The Patient Advocate Institute has developed a new course in patient advocacy, and these skills may interest nurses and other healthcare professionals on the North Coast as part of their professional development.

To date the course has been of particular interest to nurses and nurse managers, as well as allied health staff, carers, doctors and academics.

The Patient Advocate Training Course provides practical and educational assistance to people wishing to enhance their skills in patient advocacy.

A patient advocate is someone who speaks for, acts on behalf of, or otherwise assists a person seeking access to, or receiving health services, with the specific objective of assisting that person to achieve the best health outcome available to them.

The training course encourages students to develop five personal core competencies that are necessary for safe and effective advocacy, and provides a practical Framework to assist students in achieving the best patient health outcome.

The 12-week course is flexibly delivered and comprises eight online modules with assessment exercises, a weekend ‘In-Person’ Seminar in Melbourne (further seminars may be offered in other states if there are sufficient enrolments), and a final assessment.

For more information and to request a course outline visit: www.patientadvocateinstitute.com.au.

A publication of North Coast Medicare Local

spring 2014

English brothers working as registrars at Lismore AMS Jullums – Lismore Aboriginal Medical Service (formerly known as Gurgun Bulahnggelah) is delighted to have UK-born brothers James and Robert Boyd working as GP registrars there for 12 months.

The brothers, who are from Cornwall, have made Australia their home and live just down the road from each other in Lennox Head where they pursue their love of surfing (coming from one of the few areas in England where surfing is possible) and enjoy the relaxed North Coast lifestyle.

Jullums’ practice manager Christine Wilson said staff were grateful to North Coast GP Training for organising the placements for James and Robert at the clinic.

“In the past we’ve only ever had one registrar at Jullums at a time, so to have the two Boyd brothers here two days each a week is really wonderful.”

The brothers are both intending to work as GPs in the area.

After working shifts at Lismore Base Hospital as part of their medical training, James and Robert are enjoying the more sociable hours that general practice brings and the interesting mix of patients at Jullums.

“Some members of the Indigenous community don’t always seek medical help as soon as the

Dr James Boyd outside Jullums Aboriginal Medical Service.

rest of the population might, so we see some quite advanced pathology and advanced infections.

The patients are very interesting people when you get a chance to talk to them in depth about their lives, which we do when things are a bit quiet,” said James.

About Jullums Jullums has doctors available to see patients five days a week and offers a holistic health approach with a number of contracted allied health practitioners – a dietitian, a diabetes educator, a podiatrist, an exercise physiologist, a psychologist and psychiatrist.

It also runs a respiratory clinic, cardiac clinic and a renal clinic.

Christine told HealthSpeak

that Jullums’ doctors were highly experienced and passionate about their work. They are Dr Michael Douglas, Dr Andrew Binns, Dr Carol Stevenson, Dr Ant Solomon and Dr Jane Barker.

“We are very fortunate to have the best of the best here. We also have highly qualified nurses who visit Jarjums Child Care Centre in Lismore to teach kids the importance of brushing their teeth and washing their hands, and to introduce them to a staff member from Jullums, so that they will feel comfortable when they come in for an appointment,” she said.

Jullums is also enjoying a productive association with Rekindling the Spirit, a local community organisation run

New geriatric specialist in Lismore Dr Alison Semmonds is a consultant specialist physician who moved to the Northern Rivers area from Sydney last year.

She completed advanced training in Geriatrics in Concord and Royal Prince Alfred Hospitals and then worked in private practice for six years as a general physician and geriatrician at the Sydney Adventist Hospital.

Dr Semmonds’ areas of interest are in general geriatrics, perioperative medicine, delirium, dementia, falls, osteoporosis, Parkinson’s disease in the elderly and avoiding polypharmacy.

She has admitting rights to St Vincent’s Private Hospital and a clinic at the hospital which is open to new patients with a re-

Dr Alison Semmonds

ferral from their GP or specialist.

Referrals from GPs should stipulate where appropriate the request for ‘a general geriatric assessment’ with the specific issue/s to be addressed. Patients need to bring an up to date medication list or copy of their latest WebsterPak and any recent relevant x-rays or scans. Dr Semmonds

HealthSpeak A publication of North Coast Medicare Local

spring 2014

cannot make safe medication recommendations where required without the latest medication list from the patient themselves.

Conditions suitable to be referred are preoperative assessments and geriatric syndromes as priorities and general medical patients where there is clinic availability.

Dr Semmonds as a rule does not do medicolegal reports, workers compensation reports, capacity assessments for wills and other legal matters, or immigration reports.

The clinic is not a bulk billing practice but Veterans are not charged above DVA rebates.

Contact Dr Semmonds - ph 6627 9406 or fax 6627 9209.

Dr Robert Boyd with Jullums’ receptionist Alice Exton.

by Aboriginal people to benefit Aboriginal families.

Reporting adverse reactions The Therapeutic Goods Administration (TGA) encourages the reporting of all suspected adverse reactions to medicines, including vaccines, over-the-counter medicines, herbal, traditional or alternative remedies.

It particularly requests reports of: all suspected reactions to new medicines all suspected medicines interactions suspected reactions causing death, admission to hospital or prolongation of hospitalisation, increased investigations or treatment, or birth defects.

Reports may be submitted using the blue card from the TGA website (http:// www.tga.gov.au/safety/ problem-medicines-formsbluecard.htm#.Uzn_vVdxnU), online at www.tga. gov.au; by fax to (02) 6232 8392 or by email to ADR. Reports@tga.gov.au More info: www.tga.gov.au or contact the TGA’s Office of Product Review on 1800 044 114.

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Implantable Cardiac Defibrillators and end of life care Pacemakers combined with Implantable Cardiac defibrillators (ICDs) are being inserted at an increasing rate for patients at high risk of sudden death from a cardiac arrhythmia, such as in heart failure. Patients with advanced progressive illness may at some stage reach a point where continued defibrillation is no longer consistent with the goals of their care. In addition, many patients with pacemakers are unaware that they have a defibrillator as well as a pacemaker in place.

When approaching the end of life there is a risk of the patient developing rhythms that may trigger defibrillation. Delivery of shocks near the end of life may be ineffective, painful to the patient and distressing to the carers and relatives. Deactivation will not be painful and dying will not be more painful if the device is turned off.

Deactivation of ICDs can be a difficult time for patients and their relatives and issues should be addressed as early as appropriate in the patient’s management

to avoid unnecessary distress.

In progressive illness the use of Advance Care Directives can assist the patient to accurately communicate their wishes and their family to be confident in the knowledge that they are acting accordingly.

Deactivation of the defibrillator does not affect the pacemaker function, so the heart will continue to beat with the pacemaker component fully functioning Previously deactivation of these devices only took place in hospital settings under a cardiologist’s care, however this is often inappropriate when a dying patient wishes to remain at home.

Permanent ICD deactivation can be arranged by contacting the device company who will send out a technician to the patient’s home if they have written authorisation and are accompanied by a Palliative Care Nurse.

Where necessary the application of a strong clinical ring

magnet to the device will temporarily deactivate the defibrillator, however the magnet must be applied according to the specific company instructions, and permanent deactivation should be arranged as soon as possible.

The NNSW community nurses have access to consent forms and special magnets, and can apply them at the patient’s home when necessary and when indicated by the patient’s doctor.

If you have any questions you can contact Kerry Wilcox – Cardiac and Chronic Disease program manager for NNSWLHD on 66207521 or Kerry.wilcox@ ncahs.health.nsw.gov.au NSW Guidelines for the Deactivation of Implantable Cardioverter Defibrillators at the End of Life are at: www.aci.health.nsw. gov.au

Briefs

Detergents and infertility Two ingredients found in household detergents caused reproductive decline in mice, according to a new study published in Reproductive Technology, prompting concerns about the effect of these ingredients on humans.

In this study at the Virginia-Maryland College of Veterinary Medicine, researchers found that two chemicals - alkyl dimethyl benzalkonium chloride and didecyl dimethylammonium chloride - had a similar effect in mice.

These chemicals are present in an abundance of household products such as household cleaners, disinfectants, hand sanitisers and fabric softeners, but the effect they have on humans is a mystery, with more research needed on the subject.

Two awards for Greenmeadows North Coast GP Training has recognised Port Macquarie’s Greenmeadows Medical with two awards for its exceptional vocational training.

The first award was a Bronze Certificate for Greenmeadows Medical’s 10 years of service in training general practice registrars.

The practice’s principal, Dr Robert Clarke, said the entire staff took great pride in contributing to the training of future GPs. He said the teaching capacity at the practice would be improved further with another GP Supervisor, Dr Tetyana Seppi, joining Greenmeadows Medical.

The second award was the prestigious Innovation in Practice Management Award. This highly sought after award is open to more than 50 practices from Tweed to Laurieton.

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Greenmeadows’ Practice manger, Sue Mitchell, said that while she was delighted to win the award the reason behind all the award winning innovations was to provide better service for patients.

Of the many innovations recognised, the Patient Waiting Screen (see photo) in the waiting areas and coffee shop providing patients with an estimated waiting time was the one most appreciated by patients.

Additionally, Greenmeadows’ staff member Hannah Stortenbeker was chosen as North Coast Trainee of the Year from a total of 9500 trainees. She was nominated by her colleagues.

Robert said Hannah commenced in 2012 and possessed both the personality and characteristics needed to work within the practice’s team environment.

From left: Sue Mitchell, Practice manager, Dr Robert Clarke and Dr Tetyana Seppi in front of the Patient Waiting Screen.

“Hannah’s maturity, courteous manner and interpersonal skills are invaluable and she is an asset to our small business,” HealthSpeak

Robert told HealthSpeak.

Congratulations to all the staff at Greenmeadows Medical from North Coast Medicare Local.

A publication of North Coast Medicare Local

spring 2014

What is psychology?

Psychologists understand the mind and human behaviour.

They use scientific methods to study the factors that influence the way that people think, feel and learn, and evidence-based strategies and interventions to help people overcome challenges and improve their performance.

Many psychologists work directly with those experiencing difficulties, including anxiety, depression and stress. They help people to overcome relationship problems, eating disorders, learning problems, substance abuse, parenting issues, or to manage the effects of a chronic illness.

Common settings in which psychologists work include

schools, hospitals, courts, community health services, prisons, the defence forces and private practice. The complex work that psychologists do is always underpinned by research.

Many thousands of Australian psychologists work in academic or research settings, adding to this evolving understanding of human behaviour.

Some common reasons people visit a psychologist include Attention Deficit Hyperactivity Disorder, bipolar disorder, depression, eating disorders, loss and grief, lifestyle effects on health, preventing suicide and relationship problems, sexual difficulties, personal growth, fears and phobias.

Research shows psychological treatments are effective in managing many common mental health disorders.

All psychologists are legally required to register with the Psychology Board of Australia, in the same way as medical

practitioner. To find a psychologist, go to: http://www.psychology.org.au/FindaPsychologist/ Default.aspx?ID=1204 (Information from the Australian Psychological Society website at: www.psychology. org.au)

Profile Clinical psychologist Sonia Davis Sonia is a clinical psychologist at the Southern Cross University Student Counselling Service at the Lismore campus.

She also re-commenced practicing privately in Lismore last year.

She told HealthSpeak that up until her early twenties she had thoughts about becoming an architect.

“At that time, I worked in the building industry doing drafting and office work, but it wasn’t grabbing me. And as a result of a personal crisis, my first marriage falling apart, I went to see if a counsellor could help me.

“I thought I was going to see her to have my marriage fixed, but she did a much better job than that,” Sonia said with a laugh.

“She really empowered me to take the reins to get what I wanted out of life and not try to get that through relationships or through work. I was 25 and seeing this counsellor changed my life so positively.”

The counsellor offered Sonia a place on a counselling course she was running and when she joined the group Sonia said she felt like she’d ‘found her team’.

“I felt like I was in my pow-

er, it was so nice to be good at something that had meaning for me and that helped others.”

A careers advisor then suggested Sonia do a psychology degree and she went to the University of Wollongong to pursue her study while also undertaking training and volunteer work with Lifeline and other organisations. The study and work experience provided a rich training ground. After completing her degree, Sonia did an accredited fourth year.

It was while doing her PhD that she really began to appreciate the rigorous statistical, research and assessment psychology training that university had provided. Neural architecture, mind and behaviour were even more fascinating than Sonia had imagined.

The minimum of four full time years of study and a two-year internship or Masters can be completed in six years.

However, Sonia completed her study over 16 years with having a family, building a house and working for various organisations in between.

“I worked with adolescents in community mental health and in refuges and rehab for people with psychosis. Clients

HealthSpeak A publication of North Coast Medicare Local

spring 2014

were often homeless and penniless. It was strangely rewarding as it’s really humbling and you always find some common ground with people to pick them up that point and walk with them.”

Sonia’s been most active in the Third Wave of Psychology mindfulness-based psychology where meditation and compassion are foundational tools.

Having studied Buddhism and meditation since the late ‘80s, Sonia’s research thesis was

I was 25 and this counsellor changed my life so positively. along the same themes.

Because it’s about meeting with people meaningfully and helping them live richer lives, Sonia loves what she does. A big chunk of her work is with clients with post traumatic stress disorder including survivors of child sexual assault.

Other work includes coping with life transitions, dealing with grief, relationship difficulties and how to live more

authentically.

Sonia would encourage young people to consider psychology as a career as she has found it very rewarding.

“It’s also an area where there will always be work. And in the past 10 years with Medicare mental health care plans, people can get up to 10 psychology sessions a year subsidised by the government. GPs so appreciate what you are doing as psychologists are proficient in treating and promoting quality mental health. Doctors often lament they can’t spend the hour at a time with client that is needed.

“Psychology is just fascinating and along with my daily meditation practice, allows me to be fully present with people. There are so many new approaches to learn and new ways of working with people, it’s a very exciting field,” she added.

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Celebrating Dr Betty Marks

Dr Betty in her Queen Street surgery. Photo: Nolan Verheij-full / APN

After a career spanning 66 years, Murwillumbah’s Dr Betty Marks has finally retired from medical practice.

The much loved 90-year old GP finished work at the end of June with a retirement dinner to celebrate her contribution to the community at Murwillumbah

Golf Club in July.

Dr Marks was also paid tribute in Federal Parliament – the Member for Richmond, Justine Elliot spoke of her caring nature on the floor of the chamber.

“As Dr Betty said recently, it was a love of her patients that kept her working to the age of

90. She has looked after some local families for four generations.

“Long-time patients say it is not out of the ordinary for ‘Dr Betty’ to call them from the surgery at 9 pm to deliver test results,” Mrs Elliot said.

“So, Dr Betty, on behalf of the people of Richmond I thank you for your wonderful service to our community and wish you all the best in retirement.”

Ms Elliot also quoted the Tweed Daily News: “I would like to finish with Dr Betty's words from one of the papers: “There are many wonderful people who get cancers, who get terrible pains and indignities.

But if you can help in any way possible, as a friend and as a doctor, and that's mostly what GPs are, I think, it is a great privilege” North Coast Medicare Local wishes Dr Marks a wonderful retirement.

beyondblue’s big blue bus soon on North Coast beyondblue's big blue bus will arrive in the North Coast Medicare Local region in November.

In February, beyondblue set off on an 18-month journey around Australia to encourage and support people everywhere to ‘Take 1 step’ towards having better mental health.

Working with Medicare Locals and other community stakeholders on the ground, the National Roadshow has made its way through the ACT, South Australia, Western Australia, the Northern Territory and parts of Sydney and western NSW. The big blue bus will spend 10 weeks in Queensland before arriving on the North Coast around 20 November. beyondblue is working with NCML and the NewAccess program to organise community events across the region.

(Details will be available closer to the time at www.beyondblue.org.au/take1step) beyondblue CEO Georgie Harman said the National

14

Roadshow was all about encouraging people to ‘Take 1 step’ for better mental health by tuning in to how they are feeling, opening up and talking through their worries with those around them, and taking action to get help if needed.

“I encourage people to attend a Roadshow event, where they can chat to beyondblue staff and local health professionals in an informal environment, pick up free information resources and find out about local services,” she said.

“Around one million people in Australia have depression at

any given time and over two million have anxiety. These are common conditions and can affect anyone. Unfortunately, over half of all people who experience depression or anxiety don’t seek help. We need people to realise there is no shame in getting help and once they find the right help for them, they can start on the road to recovery.”

You can find out more about beyondblue’s National Roadshow at www.beyondblue.org. au/take1step and follow the bus journey on Twitter at www. twitter.com/beyondbluebus

HealthSpeak

Calling ECI therapists The National Rural and Remote Support Service (NRRSS) advises that Early Childhood Intervention (ECI) therapists are invited to register as Early Intervention Services Panel providers with the Department of Social Service (DSS) to access funding under the following programs: Better Start for Children with a Disability Initiative (Better Start) and Helping Children with Autism program By registering as a Panel provider with the DSS, therapists can help families with the cost of early intervention services for their child.

Children who are diagnosed with a disability or autism are entitled to a range of services under the programs mentioned above. Once ECI therapists are registered they can offer intervention services which will prepare the children with disability or developmental delay for school.

Eligible therapists include physiotherapist, occupational therapist, speech pathologist, orthoptist, psychologist, audiologist, optometrist, dietitian and teacher of the deaf.

More about the NRRSS The NRRSS supports innovative models of service delivery to children and families in areas with limited access to services.

It offers an informative website where therapists can discover and share models of service delivery proven to be effective in rural and remote locations. They also deliver the Peer to Peer Mentoring Program including e-training resources and also on the website are research results on the gaps in early intervention services in rural Australia.

Go to: www.sarrahtraining. com.au/register

A publication of North Coast Medicare Local

spring 2014

Two North Coast GPs honoured Mullumbimby GP Dr Michael Pelmore and retired Port Macquarie GP Dr Natarajan Subbiah have been acknowledged for their work in the Queen’s Birthday Honours. Both doctors received an Order of Australia Medal.

Dr Michael Pelmore Dr Pelmore received the Medal for service to medicine as a general practitioner and to the community of Mullumbimby.

HealthSpeak visited Michael at the Meadows Medical Centre in Mullumbimby, a town in which he has worked as a GP since 1976.

With a father who was a consultant anaesthetist, and a mother and twin sister both registered nurses, it seems Michael was always going to gravitate to a medical career. In fact, the entire family received their medical training at St Thomas’s Hospital in London.

Qualifying as a GP in 1971, Michael decided to move to Australia and drove overland in a Kombi van as far as Kathmandu where he worked for three months and then sold the van.

“There was no petrol available as it was during the Arab Israeli War, so I flew down to Australia and started working as a GP in Windsor, north-west of Sydney.

“I moved up here in 1976 when the opportunity came up. I was a bit alternate then, long hair, headbands, so the move was to be to either Nambour, Mullum or Bellingen.

“We got here and one of the doctors over the road said ‘come and join me’ which I did, then I bought him out and two other two doctors arrived and our very happy partnership began. Dr Giles Taylor and Dr Peter Bowles, both wonderful people, and we had a very, very happy association,” said Michael.

Dr Taylor has now retired to Germany but Dr Bowles is still working at the practice and still delivering babies.

Michael told HealthSpeak he always wanted to be a GP. “I just love interacting with people and being useful, which

Michael with his insturment, the charango.

Hey doc, you delivered me, do you want to see my two kids? is what it’s all about. I’ve enjoyed building relationships with families generationally. I’ve got 30something-year- olds who come in and say ‘Hey doc, you delivered me, do you want to see my two kids?’ And I think ‘Whoo, how long have I been here?’”, Michael said with a laugh.

And recently Michael was mentoring a med student from the University Of Wollongong (which the practice does on a regular basis) when he received another reminder of his general practice longevity.

“The med student was sitting there and a mother with a fiveyear-old daughter came in and I introduced the mother to the med student and she said ‘Dr Pelmore delivered my husband!’”

Michael has also served as a Visiting Medical Officer at

HealthSpeak A publication of North Coast Medicare Local

spring 2014

Mullumbimby Hospital for 38 years. In this role he’s provided inpatient, accident and emergency, obstetrics, anaesthetics and government Medical Officer work.

He’s now winding down, working two days a week. He delivered around 800 babies during his career and is pleased now not to be doing any on call work, although he’d still doing ward rounds at Mullumbimby Hospital, which he enjoys.

Like a number of doctors, Michael has also had a vibrant performing life which has proved to be a lot of fun.

He’s a popular Master of Ceremonies, supporting community events, and is an energetic charity fund raiser, appearing at l theatrical and musical performances with his band It’s Probably Us (a reference to their baby boomer status). Michael sings and plays guitar and a South American stringed instrument called the charango.

And for a long time Michael and his GP partners enjoyed playing in a band called Los Trios Stethoscope. While Michael

says he keeps his performing life pretty low profile, it sometimes comes out at the medical centre.

“Occasionally with a patient I know very well, if I have to put a cannula in or something I’ll say ‘Trust me, I’m a musician!”, he laughs.

Michael’s musical talents extend to three Dolphin Awards for two musical CDs for children that he produced in the 1990s – Get Well Soon and Well, Well, Well.

These were accredited by the NSW Department of Education and have been used extensively in local public schools.

Working in Mullum has been ‘a wonderful challenge and a great adventure’ for Michael Pelmore.

He particularly enjoys having med students and GP registrars working alongside him at the practice.

“One of our first med students from the University of Wollongong came back as a registrar and now has come back to join us and is about to get married.

And that’s really exciting because the idea of the university sending med students to the country was to get them to come back to the country.”

A keen surfer, mountain bike rider and bushwalker, Michael is happy to be a resident of the Northern Rivers where his band still plays at local hotels. Although he jokes (in beautifully modulated tones) that he might still have a career opening as a voice over man at the ABC. He plans on working for a few more years and it’s possible he might resurrect his old friend Dr Maxwell Pelican from his children’s CDs on a website, or rather on a webfoot site, as Michael points out.

Congratulations to Michael and his proud family on such selfless service to the community in a range of roles.

Dr Natarajan Subbiah Dr Subbiah received his OAM for his service to rural and remote medicine as a general practitioner.

Dr Subbiah worked in the New England town of Barraba Continued page 28 15

Pharmacist wins customer service award In late June, pharmacist Karen Rees-Pikett of Lake Cathie Medical Centre Pharmacy won the Port Macquarie News’ Top Service Star Award for her exceptional customer service.

The award is given out after local business people are nominated and customers vote in a popularity poll for the Top Service Star.

When HealthSpeak rang Karen at her pharmacy she was understandably proud of her win, attributing her landslide victory to loyal customers and the ‘hardworking team that backs her up, always willing to go above and beyond’.

The pharmacy opened two and a half years ago and Karen said the award also allowed her to further develop her relationships with customers.

“It was a talking point. I’d explain that I’d been nominated

Karen is a strong believer in old fashioned service

Karen celebrates winning the award with her staff and customers.

and that they could vote for me if they wished. And when I won, I was able to share the good news with them,” said Karen.

Karen is a strong believer in old fashioned service and says because her pharmacy is health based, and doesn’t sell cosmetics or giftware, it’s small enough so that she can personally deliver

each medication to every one of her customers, providing them with information about their medications and talk to them about their health.

She is also a keen supporter of local business.

“I’d urge everyone to shop locally. In a world where so much is done on the internet, local

businesses are suffering and jobs will go if people don’t support their local businesses.”

As well as personalised service (ensuring correct use of inhalers and devices as well as free blood pressure checks) Karen also enjoys conducting Home Medication Reviews in private homes and residential aged care facilities. These reviews provide an opportunity for the pharmacist to review the range of prescription and OTC medications a person is taking and advise on any necessary changes.

Learning how to make an ethical decision

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

On my recent flight back to the Northern Rivers from Sydney, where I attended a meeting at the NSW Ministry of Health, I enjoyed reading a copy of The Guardian Weekly.

I was intrigued by a review entitled, ‘In the face of the ultimate decision.’ by Ranjana Strivastava, a medical oncologist based in Melbourne.

The piece she wrote focused upon the ethical dilemma many health professionals face when their patients are in the throes of a long illness with multiple pathologies.

This article stimulated my thinking about such matters. All practitioners within health care have ethics training and health authorities and universities host ethics committees which serve a crucial but perhaps limited purpose.

The ethical dilemmas facing

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clinicians stem from the clinical world. A world that is fast changing as bio-technology advances, genetic research moves forward, our societies age and chronic health and life-style choices impact on our expectations of well-being.

Ethical considerations, once never even contemplated, are coming to the fore. For example, in the UK recently the House of Lords was debating whether an, ‘assisted dying bill’, should become law.

Oregon, in the USA, passed such an act in 1994, followed

by Washington State in 2008.

Belgium and The Nederlands

also have assisted suicide laws, as does Switzerland. This is a highly emotional subject and it’s a difficult topic for academics to discuss with the student body. Yet it cannot be ignored.

It is part of the continuum of care and needs to be incorporated into any care model.

Practitioners need to be schooled so that they can work with real-life patients with real-life dilemmas. Practitioners need to know how to discuss their insights so that a consensus may be shaped - a consensus which allows the flaws in our thinking to be outed in order to deal with any personal conflict that may arise.

To help our students cope with these emerging ethical dilemmas and better prepare the next generation of health practitioners, we at Southern Cross University are investing heavily in clinical teaching and learning. To that end, over the coming year we hope to establish a Centre for Excellence in Clinical Education based within the University Clinic.

HealthSpeak

The Clinic hosts students from many disciplines along with qualified practitioners.

Incorporating the principles identified by the World Health Organisation, the Centre will aim to develop best models of pedagogy for the clinical professions. These approaches to learning will stimulate skill and knowledge development based on person centred care.

This rubric allows the learner to move through a hierarchy of knowledge, achieving capability for patient care management along the way.

These capabilities all rest on the ability to work with patients as they face the various ethical dilemmas surrounding health care. Through the introduction of inter professional and clinical supervision, the students will understand their professional role more fully and better engage with patients, thereby meeting the hallmarks of a different type of professionalism, one more suited to the demands of today’s health care.

A publication of North Coast Medicare Local

spring 2014

Understanding health professionals: Looking at occupational therapy Occupational therapy (OT) is a client-centred health profession concerned with promoting health and well being through occupation. The primary goal of OT is to enable people to participate in the activities of everyday life. Occupational therapists achieve this by working with people and communities to enhance their ability to engage in their occupations or by modifying the occupation or the environment to better support their occupational engagement.

Occupational therapists do a variety of work including: Working with children: Helping children

achieve their developmental milestones such as fine motor skills and hand-eye coordination.

Educating and involving parents and carers in the normal child development and learning Rehabilitation and aged care: Helping clients regain or enhance their lives after events such as hip replacement or stroke.

Assessing and modifying clients’ home and community environments to improve safety and indepen-

dence.

Prescribing and educating clients and carers in the use of adaptive equipment to assist function.

nating return to work programs.

Educating clients in safe work practices.

Modifying the work environment to prevent or minimise injuries.

Acute care: Specialist interventions in areas including surgery, burns, HIV and acute mental health.

Assessing clients’ cognition, function and psychosocial needs.

Monitoring clients’ function and progress, prescribing adaptive equipment to ensure safety upon discharge

Mental health: Designing individual and group programs and activities to enhance independence in everyday activities.

Developing coping in overcoming mental health issues.

Improving’ confidence and self esteem in social situations.

Injury management: Using specialised assessments to determine the functional requirements of various jobs, and clients’ capacity to return to work.

Designing and coordi-

To become a qualified occupational therapist, you need to complete an undergraduate course in occupational therapy at university. To find an occupational therapist in your area, go to: http://www.otaus.com.au/ find-an-occupational-therapist

Profile Occupational Therapist Sara Walker Occupational therapy (OT) was put into Sara’s sights early, when it was shortlisted for her by a careers advisor. She then gained a Year 10 work experience placement in OT at Gosford Hospital and loved the work.

“I wanted a career that helped people, and being practical and creative were personal strengths of mine,” Sara explained.

After exhausting her travel bug and gaining secretarial and admin skills at TAFE, Sara enrolled as a mature aged student in OT at Newcastle University.

After graduating, she worked in private and public health settings including stroke rehabilitation, community mental health, occupational rehabilitation and driving assessments.

She then commenced a private practice in community rehabilitation on the Central Coast when her children came along as it afforded her the flexibility to balance work and home life.

Six years ago, the family moved to the Mid North Coast.

“It was for a lifestyle change and now I call it home,” said Sara.

Her first job up here was working as a casual OT at Bellingen Hospital for some years, which she says was a really great way to help her meet people and settle into her new community.

A busy Mum, Sara then returned to private practice for the flexibility, and now runs Coast OT. She recently expanded to offer community rehab services for adults from Coffs Harbour to Kempsey.

“I also have a special interest in Aboriginal health and have just launched an online DVD called ‘Living with Chronic Conditions’. It’s designed to empower patients with chronic diseases and their carers to function well in their everyday life.”

To gain access to the DVD, go to: www.livingwithchronicconditions.net Sara enjoys her work which allows her to help people with chronic conditions remain in their own homes and enables

HealthSpeak A publication of North Coast Medicare Local

spring 2014

them to better function in their daily lives.

“Quality of life is everything, as anyone who has ever suffered serious health problems will testify. I’m the one who can help them get on with their lives when their condition can’t be cured. I love working in the community, seeing people in their homes, in their comfort zones, it’s very different to treating people in hospital. Home is where people want to be and OTs

I’m the one who can help them get on with their lives... are very skilled at enabling people to function safely and independently, no matter their disability.”

For anyone wanting to help people in a practical way, Sara recommends a career in occupational therapy and believes life experience only adds to an

OT’s professional skills.

“A bit of life experience goes a long way when you are working in health care! OT could suit young or old. With our ageing population, OTs play a strong role in keeping people at home, so there will be a long term demand for OT services,” she told HealthSpeak.

Sara also pointed out the many opportunities available for OTs – many of which are outlined at the beginning of this article.

“OTs can work in all areas of health care, treating people from the cradle to the grave, with opportunities in both the public and private health care settings,” she added.

Contact Sara on 0418 699 785 or email: CoastOT@bigpond.com

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PD Warrior – Fighting Back Against Parkinson’s Disease

By Jim Preece

Parkinson’s Disease Parkinson’s Disease (PD) is a progressive movement disorder affecting the basal ganglia, characterised by tremor, bradykinesia, rigidity & postural instability PD is the second most common degenerative neurological condition after Alzheimer’s disease In Australia, 30 people are diagnosed with PD every day and around 80,000 people are living with the disease 20% of people with PD are under 65 and 10% diagnosed are under 40

About PD Warrior PD Warrior is an exercise program developed by specialist neurological physiotherapists in Sydney, based on the latest research into exercise and PD. It uses a challenging combination of high effort exercise (working at 80% of self-perceived maximum exertion), large amplitude movements and complex physical and mental 'multi-tasking'. It is delivered as a combination of a home exercise program and circuit class. Combinations such as boxing while counting backwards in sevens, or marching while turning an arm crank and naming the countries in Europe, are typical sights in a PD Warrior class.

Working on these complex combinations translates into everyday movements becoming easier and PD symptoms improving.

How does it work?

PD Warrior addresses the primary impairments of PD directly by engaging and challenging the movement pathways and cells in the basal ganglia.

This drives neuro-plastic and neuro-restorative changes, as 18

well as normalising central motor output. Moreover, exercise induces production of endogenous neurotrophic factors, resulting in a neuro-protective effect, potentially slowing down the progression of the disease. Currently, exercise is the only intervention we know of with the potential to alter the disease course.

Research also shows that sedentary behaviour actively contributes to and accelerates degeneration in PD, so the earlier people with Parkinson’s start exercising, the better. PD Warrior hopes to create a paradigm change in the management of early PD - with people seen as close as possible to the time of diagnosis to maximise the opportunity of disease reversibility. It is important to emphasise that to achieve the levels of motor output required to drive neuro-plastic change, patients must be on an optimal Parkinson’s medication regimen.

PD Warriors Iffat Farah is a retired university professor from Ballina who was diagnosed with PD in 2012: “At first my left arm wouldn’t ‘go’.

Not being able to swing the arm and feeling that the arm was heavy came first, and that started affecting my walking. I love walking, but I can’t walk as fast as I could.

Next was pain in the shoulder, then came tremors in my hand, followed by my fingers becoming tight and ‘claw like’. It affected my confidence in what I can do.”

Iffat started PD Warrior in April and now does the exercises six days a week: “Each movement is very specific and is helping me where there is rigidity. Some exercises I found very difficult with coordination at first, but today I can do them without thinking, and I realise that my leg and arm are really moving as they should move! I notice that on the days I have done the exercises, I walk better. I think I have more confidence, because the more I push myself in the exercises and

PD Warrior Iffat Farah with physiotherapist Jim Preece.

Each movement is very specific and is helping me where there is rigidity. don’t topple over, I feel like ‘oh, I can do this! I can push myself ’. I know it won’t cure me, but it will make my life better.”

Another recent PD Warrior is a 52-year-old high school teacher, who contacted me one week after being diagnosed with PD. Her main concern was right upper limb tremor, which made it impossible for her to write on the white board, to the point where she had resorted to writing left-handed. After a few months of exercises she reported that her tremor was not even recognisable most of the time and she was again using the white board. By controlling and improving her symptoms with exercise, she has also been able to delay starting on Parkinson’s medications.

Exercise as Medicine Dr Bob Lodge is a Specialist General Physician practicing at Bangalow Consulting Centre.

He believes that physiotherapy for PD has been under-recognised and under-utilised: “The results to date - and I’ve probably HealthSpeak

referred about 10 patients to PD Warrior - have been all positive and there have been a couple of quite dramatic improvements in patients. The dramatic improvement has been not only in their functional capacity, but also in their confidence that they can self-manage this condition or deal with it using methods other than medications, and that gives people a huge amount of confidence.

“PD Warrior, now that it’s available in our region, should be openly and warmly embraced and considered for all patients with a recent diagnosis and during the first few years of therapy.

It would be really useful if GPs thought PD Warrior at the same time as they were thinking ‘Ldopa,” he added.

As health professionals, we can’t afford to understate the role of exercise in improving mobility, confidence and quality of life in PD. Exercise is medicine and we need to start prescribing it correctly. PD Warrior is about getting people to take control and fight back against PD so they can continue to live active and full lives.

Jim Preece is a physiotherapist with a special interest in PD. He moved to Mullumbimby to bring PD Warrior to the North Coast. Action Potential Physiotherapy is a mobile service covering Ballina, Lismore, Byron and Tweed areas. Contact Jim on 0403 880 817 or actionpotentialphysio@ outlook.com

A publication of North Coast Medicare Local

spring 2014

Urological Paediatric Surgeon in the Hunter For general practices operating around Coffs Harbour and further south, Dr John Cassey is the closest Urological and General Paediatric surgeon to your area.

John’s sub specialty is in urogenital problems. He also lectures in paediatrics. He sees children with a range of congenital and acquired conditions including

insufflation.

Dr John Cassey with Giao Chi, chief medical interpreter during a break in surgery Lam Dong Hospital, Vietnam.

Scenario Two: absent testes History: Four-year-old boy brought to you by his parents because they have never seen his right testis Examination You can feel a normal sized left testis in the scrotum and you think you can feel the right one in the groin. Your notes do not record any issues during his infant checks.

Lumps and bumps External or internal genital problems Upper and Lower GI problems Extra-cardiac thoracic Oncology Routine appointments are available within three weeks and urgent appointments can be accommodated. Patients are bulk billed on request due to financial difficulties or if the child has a chronic condition. John is happy to review films and other results, and is also available to speak at a practice or a network group meeting.

Additionally, he produces a regular newsletter for GPs in his area, and it’s something that he thought other specialists or allied health providers might like to emulate. A copy of John’s newsletter can be viewed at: http://healthynorthcoast.org.au/ wp-content/uploads/2014/08/ Testes-and-inguinla-herniaenewsletter.pdf John is also conducting ongoing clinical research into thermal regulation of children under anaesthesia, pain management and minimally invasive management of congenital urinary tract obstruction. Contact him on (02)4954 3888 or email: jcpaed@ iinet.net.au He kindly provided HealthSpeak with two clinical scenarios.

Clinical scenarios Scenario One: Inguinal lumps in girls History Three-month-old girl

presents with a history of bilateral groin lumps appearing yesterday Lumps were around the pubic tubercles and into the labia majora Initially large (2cm) and associated with some crying, although the baby cries a lot anyway Became small over the period of a nappy change with left now gone and small lump on the right Examination You note a baby with an elongated firm lump in the right inguinal region adjacent to the tubercle – 10mm X 6mm. It is quite mobile and non-tender with no overlying skin change.

Diagnosis and Management Okay…sounds like a hernia? Yes! What is the residual ump? The ovary. Really? Yes. Could it be anything else? Well, there are no lymph glands in that spot. So, the only other possibility is a testis.

There is a rare condition called androgen insensitivity syndrome (look it up if you want). These individuals have phenotypically female sex with chromosomal male sex, and, of course, no female internal organs.

Do you need to do additional tests or give additional explana-

HealthSpeak A publication of North Coast Medicare Local

spring 2014

tion to the parents of a girl with an ovary in her groin?

Not unless it is bilateral or it feels larger than usual. If that were the case, I would raise the possibility and do chromosomes.

Pelvic ultrasonography may not definitively identify a uterus at this stage.

Do you need to respond quicker in this situation? All babies with herniae need a reasonably quick response as the hernia obstructs more often than in older children. The ovary adds a small additional concern.

Other stuff Is ultrasonography (US) for inguinal herniae useful? No. There is no value in arranging a US for a baby/child presenting with a history of a groin lump. If the history is clear, it is a hernia – even if you can’t see it. Ultrasonography will NOT show a hernia sac. Inguinal herniotomy is a common, simple, day stay procedure with a rapid recovery (often no post-op analgesia with a good intraoperative block in children under 3 years of age.

Properly sited, a mature scar is undetectable.

A laparoscopic approach is an alternative with no clear advantages regarding cosmesis and an increase in postoperative pain due to the umbilical incision and

Diagnosis and Management Okay, it is either a retractile or an undescended testis. It matters, of course, because retractile testes are an ‘almost normal’ child variant and a child with an undescended testis should be offered surgery.

There is no non-clinical way of telling the difference between a retractile and an undescended testis. Testicular examination can be greatly challenging, particularly in a chubby, non-cooperative two-year-old!

In an attempt at making things a bit easier, I offer the following link to testicular examination. It is being performed by a mother. https://www.sugarsync.com/pf/ DB60759_61353600_13671 The essential points of technique she demonstrates are: Boy is lying on his back in a frog leg position; the examiner’s thumb and index/middle fingers of one hand were firmly on the pubic tubercles before approaching the scrotum; the index finger of the other hand pushes into pubic rami at the base of the scrotum BEFORE pushing the scrotum up; the thumb of the same hand starts at pubic tubercle and, quite firmly pulls the scrotum so that skin runs between index finger and thumb.

The testis will be felt at the back of the thumb pad. This means there is no squeezing and no pain.

Now that you have decided, it’s Continued page 36 19

The Koori Grapevine Welcome to hospital pamphlet Some time ago, it became apparent to health workers in the Hastings Macleay area that a welcome pamphlet for Aboriginal people coming to hospital would be helpful to explain the services available to them and how to access these.

At the same time, due to the over representation of Aboriginal people in our prison system, there was discussion around the need for people leaving gaol to be made aware of relevant community services.

The resulting pamphlet, Sprocket for your Pocket, meets both needs.

The pamphlet came about due to a collaboration between staff from Port Macquarie and Kempsey hospitals, North Coast Medicare Local and Community Health. North Coast Medicare Local provided the funding for design and printing of the pamphlet.

The sprocket will be distributed to all Aboriginal patients in hospital in Port Macquarie and Kempsey, prisoners leaving

Bundjalung woman at One21seventy

From left: Lois Sallustio, AHLO PMQ Base Hospital; Judy Hancock, Aboriginal Community Options Manager, Booroogen Djugun; Annie Orenshaw, IHPO at NCML; Loretta Smith, Aboriginal Chronic Care Worker, Kempsey District Hospital; Deb Cushing CCSS Coordinator, NCML; Sue Thompson, CNS 48 hour Follow up Connecting Care; Susan Minns, Connecting Care Chronic Disease Program MNCLHD.

detention, and anyone in the community who would like one.

A similar pamphlet will soon be ready for the Coffs Harbour area.

The sprocket was launched on August 7 and distributed

the same day at the Birpai Land Council Children’s Day. For more information, contact Annie Orenshaw, Indigenous Health Project Officer at NCML on 6583 3600.

Birthweights improving The risk of an Aboriginal and Torres Strait Islander mother giving birth to a low birthweight baby has fallen significantly.

While Indigenous mothers are still twice as likely as non-Indigenous mothers to have low birthweight babies (12.6% and 6.0% respectively), analyses showed that the low birthweight rate among Indigenous babies dropped by nine per cent between 2000 and 2011, according to the Birthweight of babies born to Indigenous mothers report.

AIHW spokesperson Dr Fadwa Al-Yaman said that this drop in the low birthweight rate for Indigenous women

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had led to a significant narrowing of the gap in the low birthweight rate between Indigenous and non-Indigenous mothers over the decade.

Dr Al-Yaman said low birthweight was associated with a range of adverse health outcomes, including fetal and neonatal death and morbidity, and the development of chronic diseases later in life.

He said a range of factors were associated with birthweight, including maternal smoking during pregnancy, antenatal care and pre-term births.

“Half of all Indigenous mothers who gave birth in 2011 reported smoking

Koori Grapevine

during pregnancy compared with 12% of non-Indigenous mothers. The smoking rate among Indigenous mothers fell from 54% in 2005 to 50% in 2011-with a greater fall in the rate among non-Indigenous mother - highlighting considerable scope for further improvements.”

There were also improvements in antenatal care and pre-term births for Indigenous women over the decade. The rate of Indigenous women attending at least one antenatal session increased between 2000 and 2011, while the rate of pre-term births declined.

Sarah Kania, a Bundjalung woman, is the new manager for One21seventy, the National for Quality Improvement in Indigenous Health Care in Brisbane.

Sarah grew up in Ipswich in Queensland and is a proud mother of three and grandmother of one. She has 15 years’ experience working in health in urban, rural and remote communities.

One21seventy aims to strengthen the quality improvement capability of the Indigenous primary health care workforce; produce and deliver evidence-based products and services; and be a national leader in CQI knowledge production and transition in Indigenous Primary Health Care.

The organisation provides tools, training and support for primary health care centres and providers to use and is located in Brisbane.

Sarah is passionate about improving inequalities in the health gap for Aboriginal and Torres Strait Islander people.

She is looking forward to building relationships with the One21seventy services and stakeholders.

A publication of North Coast Medicare Local

winter 2014

NAIDOC Celebrations 2014 NCML staff really got into the swing of this year’s NAIDOC Week festivities with the theme ‘Serving Country – Centenary and Beyond’.

NAIDOC stands for National Aborigines and Islanders Day Observance Committee and NAIDOC week is a time to celebrate Aboriginal and Torres Strait Islander cultures.

It’s an opportunity to recognise the contributions that Indigenous Australians make to our country and our society.

North Coast Medicare Local’s Closing the Gap teams held information stalls at Community Days which included other activities such as a kids’ colouring in table and competitions throughout the North Coast.

NCML staff also laid wreaths

at cenotaphs to remember those Aboriginal and Torres Strait community members who died serving their country.

Each town hosted activities and events with their own particular flavour. At Byron Bay there was a street march, in the Tweed, members of the Queensland mob marched down and joined the Tweed mob in their celebrations of culture.

Uncle Archie Roach was also a welcome attraction, performing at Southern Cross University campuses in Lismore and Coffs Harbour.

NCML’s Closing the Gap Team in Coffs Harbour was recognised with awards at events in Nambucca Heads and Coffs Harbour for its work in education the community about health and wellbeing topics.

Susan Parker Pavlovic and Leisa Lavelle at the Tweed celebration

NCML’s Coffs Harbour CTG staff with renowned singer Archie Roach.

A colourful community event at Port Macquarie.

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NCML’s Helen Lambert with a veteran at the Coffs’ ceremony.

A publication of North Coast Medicare Local

The Lismore CTG crew at the SCU campus celebrations.

Koori Grapevine

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Arts Health and Wellbeing Big steps taken at Little Dragons workshop In July, the Alstonville-based SPRUNG!! Integrated Dance Theatre group ran a five-day school holiday integrated creative arts camp for kids with and without a disability which combined creating artworks and dance movement.

Alstonville studio principal Sue Whiteman said a big part of the success of Little Dragons was instruction and assistance provided by art therapist and former dancer Jeanette Krohn.

Jeanette told HealthSpeak that over the five day workshop the young people moved between creating art and dance.

“I got them engaged in mark making – expressing themselves on paper with vivid coloured oil pastel crayons. We had a range of children, some with Down Syndrome, some on the autism spectrum and kids without a disability and every single one of them eventually got down to making art. It was lovely to see how seamlessly the kids interacted with each other,” she said.

Sue and Jeanette were ‘blown away’ by the volume and quality of the art created during the workshop.

Jeanette said it was also pleasing to be able to offer the kids with disabilities some quiet space and free time to explore their expression, as often their

lives were very structured, being ferried about by carers.

“One little girl, who perhaps had ADHD, took some time to get involved, but it was great to see her become really engaged with painting, she really loved it,” said Jeanette.

The children’s artworks will be developed for a special exhibition to be held in December.

Following on from the success of the Little Dragons workshop, Lone Goat Gallery in Byron Bay exhibited photographs taken by Katrina Folkwell during a rehearsal of a SPRUNG!! work in progress led by Artistic Director Michael Hennessy. The exhibition was titled “A Day in the Life…

Since it began in 2012, SPRUNG!! has gone from strength to strength. Sprung!! incorporated on in May last year and is a registered not-for-profit organisation with an exciting and dynamic Board. It also has a new General Manager, John Rado.

Additionally, SPRUNG!! is providing mentorships for talented young artists with a disability. To contact SPRUNG!!, phone …..

Photo above: Teacher Sue Whiteman with Sienna Shepherd and Nadia Layton.

Needlepainter: Bellingen exhibition Lizard Island

Dutch born Jerome Speekman’s exquisite embroidery work is on show at the Bellingen Gallery until September 18.

As an apprentice sailor, Jerome fell in love with Australia at the age of 15.

“When I arrived in Brisbane I was amazed when I saw a whole harbour full of different coloured jelly fish and I loved the wide 22

spaces, the sunshine and the chance of meeting people related to the original habitants that had a culture many thousands of years older than mine,” he said.

Jerome was 30 years old when illness led him to turn his hands to embroidery, with no formal training.

“My first work was on a jacket and whenever I wore it, so

many ladies told me that I was a “Master” that it encouraged me to do more. I progressed to wall hangings because shirts, jackets etc wear out.”

Jerome is inspired by Australian native fauna and flora and for the past 25 years he has rendered these images in needlework in a realistic fashion.

He’s also tackled portraits and more free form work and as a hobby he makes 3D short animation movies.

His current theme is ‘Naughty’ and he’d like to exhibit in the next few years in China, the country of embroideries.

His recent works are vivid and confronting – worlds away from traditional needlework and well worth a look.

Providing art on prescription Discussions are underway in the UK city of Hull for an idea that could help people with mental health or weight issues to improve their confidence and fitness.

There is talk of overweight patients and people with depression being given a doctor’s prescription to volunteer at the UK City of Culture event in 2017.

More than 3,000 volunteers will be required at the event and some of the projects will involve a great deal of physical activity.

The man proposing the idea, Andrew Dixon, said there would also be a benefit to the volunteers with the mental wellbeing of coming together and the huge groups of people they will meet.

Mr Dixon said the plan was to use Hull’s City of Culture 2017 to make a difference to one life in the city every day.

“We want to promote a positive health message and improve the medical, emotional and spiritual status of our citizens. We can make them feel better about the city, their life and improve self-esteem” he explained.

Mr Dixon said organisers were working with Hull's public health team to see how the City of Culture could improve health.

“We want to make sure this has a role in transforming how people feel about themselves in the city.”

HealthSpeak

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The art of starting and finishing together

By Janis Balodis There are two golden rules for an orchestra: start together and finish together. The public doesn’t give a damn about what goes on in between – Sir Thomas Beecham, English conductor Learning to play an instrument well, any instrument, requires hours and hours, adding up to years of lonely and often frustrating practice. The chance to play as part of an orchestra is a golden opportunity. The Northern Rivers Conservatorium has just held its third Northern Rivers Youth Orchestra music camp for 65 students from the Clarence to the Tweed, regardless of their level of ability.

Luis Fernando Madrid was the guest conductor charged with instilling the golden rules.

And to assist with all that goes on in between were 12 student buddies who travelled up from the Sydney Conservatorium and tutors from the Northern Rivers Conservatorium.

Luis hails from Cartagena in Colombia where he completed studies in piano and conducting.

In 2010 he was awarded a scholarship to study for his Masters in conducting with Professor Imre Pallo at the Sydney Conservatorium. Having been awarded his Masters in 2013, Luis has been offered the opportunity to complete his Doctorate in pedagogical aspects of conducting.

As well as conducting orchestras in South America and Europe, Luis is a specialist in

conducting choirs and wind ensembles. His skills have been much in demand in schools throughout New South Wales, particularly in Granville in western Sydney where he is working with disadvantaged children.

Luis admits that this work is challenging, as they often have to deal with social and domestic issues.

“Some are starting from zero but in a few weeks they can play some simple tunes. And when they are playing music they change. You can see it in their faces.”

It is because of his special rapport with children that Northern Rivers Conservatorium requested that Luis Fernando Madrid conduct their Youth Orchestra for the second year running.

The camp is three days of intensive music rehearsals and tutorials. The participants had prepared and learned the music prior to attending the camp.

The different sections of the orchestra (strings, woodwind, brass, percussion) now rehearsed separately under the guidance of their tutors and student buddies.

And there was a full orchestra rehearsal each day leading to a public concert on the final evening.

The conductor’s task is to bring the different sections together into a harmonious community. Luis introduces and emphasises orchestral etiquette,

HealthSpeak A publication of North Coast Medicare Local

When they are playing music they change. You can see it in their faces Luis Fernando Madrid

how to behave, how to follow instruction, the need to cooperate with and respect each other, not just the conductor. Luis said he found the children easy to work with and that he noticed that there had been progress from last year.

On the first morning the full orchestra rehearsal focuses on sight-reading of all the pieces and the players gaining a feel for the level of the conductor’s expectations. The first time through the concern is for accuracy of pitch. On the second morning the playing is better with evident gains in confidence.

There is more listening to each other and “less dependence on the paper”, the written music.

The emphasis is more on musical phrasing. After two days rehearsal, together and in sections, the level of improvement is significant. The third time through is more about the playing and

enjoying the experience.

Luis is particularly interested in how learning to play music can give children and the wider community a different perspective on life, and playing together with others is not only fun, it makes us better people. Even when society fails to recognise the value of music making, and individuals struggle to believe they are worthy of playing and enjoying it, “Music is in itself a therapy.”

An orchestra is much greater than the sum of its parts. The undoubted feelings of accomplishment and the audience applause are immediate rewards.

Longer term benefits are the lifting of spirit and sense of purpose derived from the collective encouragement of a group and inspirational leadership. A difficult challenge was mastered by starting and finishing together, and by enjoying what goes on in between. The final concert was a triumph.

Northern Rivers Conservatorium Youth Orchestra workshop is held during the July school holidays.

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Med students choose North Coast The University Centre for Rural Health (UCRH) at Lismore has welcomed 40 med students to the area with an orientation including social and cultural activities.

The senior medical students from the University of Wollongong and the University of Western Sydney have placements to complete the 12-month practical component of their training in the Northern Rivers.

Placements include Lismore Base Hospital, Grafton Base Hospital and Murwillumbah District Hospital, Aboriginal Medical Services, and GP practices.

“These students, and others who will come throughout the year, choose the Northern Rivers because of the reputation of local health facilities and of the many skilled clinicians who generously share their knowledge and time for the benefit of the next generation of doctors,” said Dr Michael Douglas, UCRH Director of Education.

Michael said that research

Briefs

Smoking down, and drugs up While the National Drugs Strategy Household Survey showed a decrease in smoking rates, more people are misusing pharmaceutical drugs and crystal meth.

Daily smoking among people aged 14 and up declined from 15.1 per cent in 2010 to 12.8 per cent in 2013. Since 1991, daily smoking rates have almost halved.

AMA President Dr Brian Owler said the decrease in tobacco use was testament to Australia’s comprehensive approach to tobacco reform, and demonstrates the effectiveness of plain packaging and increased tobacco excises.”

The survey also found that while there had been a decline in those aged 12 -17 consuming alcohol, and illicit drugs

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Fourth year med students from UWS enjoyed ochre face painting during their excursion to Byron Bay. From left: Kate Sandy, Thomas Pearson, Sarah Kong and Matthew Knox.

showed that clinical students who did their placement in a regional/rural area were more likely to settle and work in ‘the bush’ after graduation.

“Supervised experience of this kind is an essential part of becoming a qualified doctor, but it’s much more than that.

We bring to the students a broad understanding of their role as a

such as heroin and ecstasy, the use of crystal meth (ice) had doubled and more people were misusing pharmaceuticals.

Caring daughters Research suggests that daughters care for their elderly parents as much as they can, while sons help very little in comparison. The new study by researchers at Princeton in the USA shows that daughters spend twice as much time each month caring for elderly parents than sons do.

Lead researcher Angelina Grigoryeva said that numerous studies repot negatie mental health consequences, including a higher mortality rate, for those who care for elderly family members.

She adds that such caregivers frequently juggle caring for their parents with employment, possibly resulting in career sacrifices and lower earnings.

professional, and as an advocate, with a clear understanding of what it means to be a leader in the community,” he added.

Antibiotic resistance – take the pledge The National Prescribing Service (NPS) has started a campaign to tackle antibiotic resistance.

In their words, it’s ‘everyone's problem’. All health professionals have a responsibility to preserve the miracle of antibiotics.

The campaign organisers believe that whether you prescribe, dispense or provide advice about antibiotics you can make a difference.

They are asking health professionals to take a pledge which you can view here: http://www.nps.org.au/ medicines/infections-and-infestations/antibiotics/for-healthprofesionals/resistance-fighterpledge If 25,000 health professionals pledge to preserve the miracle of antibiotics, the NPS will be nearer its target to bring Australia into line with the OECD country average for antibiotic prescribing.

Fewer than 5000 health professionals have so far taken the pledge. Why not boost those numbers?

HealthSpeak

NPS MedicineWise on asthma control The latest NPS MedicineWise program offered to GPs through North Coast Medicare Local’s pharmacists is titled Exploring Inhaled Medicines use and Asthma Control.

Evidence suggests that the condition could be better assessed and managed in a large proportion of patients, especially children under 15 years who bear the majority of the disease burden.

The program will look at assessment of asthma control and review of treatment, including confirming a diagnosis of asthma, addressing modifiable risk factors, ensuring correct inhaler technique and optimising use of inhaled medicines in ongoing asthma management.

Highlights from the recently updated National Asthma Handbook will also be discussed.

The program also explores the benefits of educating patients about self-management of their asthma, including selfmonitoring, having an up to date written asthma action plan and returning to the doctor for regular review.

Other learning activities include group education sessions, a clinical e-audit, an online case study and an online learning module for nurses.

For more information: Tweed Valley: Pharmacist Hill Hayward on 07 5523 5599 Northern Rivers: Pharmacist Sally Herbert on 6622 4453 Mid North Coast: Pharmacist Michael Driscoll on 6659 1800 Hastings Macleay: Pharmacist Lesley Burrett on 6583 3600

A publication of North Coast Medicare Local

spring 2014

The Doctor will see you ALL now Shared Medical Appointments

By Garry Egger Shared Medical Appointments (SMAs), where doctors see patients in groups of six to 12 over one hour, are set to become the next big thing in chronic disease management, with the first Australian trials being completed on the North Coast.

SMAs, also called group visits, have been defined as: “A series of individual medical visits carried out sequentially in a supportive group setting where all can listen, interact and learn.” They have been used in the US for over a decade, but haven’t taken off in Australia because of the belief that they don’t qualify for medical benefits.

However, discussions with Medicare and a submission for a special item number through the Australian Lifestyle Medicine Association (ALMA), has opened up the process for consideration.

SMAs offer the advantages of more time with the doctor; peer support from fellow sufferers and input from other allied health professionals. Patients claim they learn more, don’t have to remember all the questions they usually forget (because others ask them for them), and enjoy the process better than

their usual care.

SMAs have particular appeal as a better way of managing the 70% of consultations that are now due to chronic diseases.

These require longer term management and more care than the infectious diseases of the past.

Interestingly, doctors claim to also enjoy the SMA as a break from the routine of advising dietary, exercise, stress management changes that have to be repeated ad nauseam.

SMAs require at minimum, a doctor, and a trained facilitator.

However other experts can join if desired. It also is possible to have observers – possibly enhancing the student experience.

As the key person, the facilitator is responsible for organising the group, keeping medical records, moving the doctor through individual consults and generally keeping the show on the road for an hour to an hour-and-a-half. Because the facilitator records medical notes it also means the doctor can focus more on doctoring.

The facilitator (usually a practice nurse or allied health professional) can also contribute to the consult. Groups can be homogenous (all diabetes, heart problems etc, or heterogeneous any chronic disease).

The big question has been, ‘would SMAs work in Australia?’

As part of an RACGP grant, ALMA, together with the

SMA Australian case studies

Baker International Diabetes Institute in Melbourne, is completing a pilot on the North Coast and in Western NSW. After around 20 groups with almost 150 patient visits, all the signs are positive.

“I’ve done lots of diabetes education groups. But I’ve learned more in one of these (SMAs) than in all of those.”

Pete, 42, truck driver As with published US data, there is almost 100% acceptance of the process with patients and providers involved in the trials.

Confidentiality is no problem, because attendees are asked to sign a confidentiality agreement.

In thousands of SMAs in the US and Europe however, not one case of breach of confidentiality has been noted.

Up-skilling is required for nurses and others to act as facilitators, and to this end ALMA is planning the first of a series of one-day training programs on the Gold Coast in November (see ad this page).

Of course if the answer is ‘no’ to the question ‘do you want extra people with that?’ when patients book a consultation , they can always go back to the usual system. It’s likely however that Gen Z will see group medical visits as part of the medical furniture of the future.

Dave

Dave is in his early 40s and has had HIV and all its complications for 10 years. He’d had a cancerous scrotum removed, had a heart attack two years previously and suffered serious kidney problems as well as type 2 diabetes.

After confiding all this to the group, Dave was asked at the end of that SMA whether he had enjoyed the process and why. His response: “It makes you realise you’re not so badly off after all when you hear everybody else’s problems!”

Susan

Susan complained of lack of sleep, but only in her second SMA did she admit that she had that solved now:”… because I’ve stopped drinking the 70 cans of full strength coke that I drank per week”, a fact that her GP had no knowledge of before it came out in the group.

HealthSpeak A publication of North Coast Medicare Local

spring 2014

Expressions of Interest Shared Medical Appointment Facilitator Training For Practice Nurses and Allied Health Professionals Develop a new skill for increasing efficiencies and outcomes, and improving work satisfaction.

CPD Points + ALMA Certification provided To be held at Gold Coast Medicare Local, Burleigh Heads, Saturday November 9 Introductory offer – First 20 half price ($295) Details & booking: Phone: 0428 288 526 Email: john.stevens@scu.edu.au

25

Making speech pathology a priority

By Penny Hanley National Rural Health Alliance Earlier this year, the National Rural Health Alliance (NRHA) made a submission to the Senate Community Affairs Committee Inquiry on the prevalence of speech disorders and speech pathology services in Australia.

The NRHA welcomed this inquiry. Awareness of speech pathology services and the situations in which they can assist is quite low outside the major cities. This lack of awareness, coupled with poor availability of speech pathology services, contributes to under-diagnosis and to underestimates of the prevalence of speech, language and communication disorders. The result is less than optimal treatment of many disorders for people in rural and remote areas.

Speech pathologists diagnose and treat communication disorders. They play an important role in helping people of all ages, from babies with a cleft palate to elderly patients who struggle with swallowing, which is vital for taking medicines and for getting enough nutrition.

A speech pathologist might work with a young man with brain injury from a motorbike accident to help him speak clearly again, or help an older person with dementia to com-

26

municate with family and carers.

More than 6.7 million people live in Australia’s rural and remote areas and there are proportionally few speech pathologists in rural compared with metropolitan areas. As with so many other health professionals, their prevalence decreases with remoteness.

A high proportion of Aboriginal and Torres Strait Islander people live in rural and remote areas. Indigenous children have very high rates of middle ear disease which can lead to hearing loss and this affects the development of speech and language skills.

Children with a language impairment are six times more likely to have problems with reading than those without and 46 per cent of young Australian law offenders have a language impairment.

Even a mild communication impairment can have a serious impact on a person’s daily life, and on school and employment opportunities.

No matter where they live, infants and children should have the speech and communication skills that will fit them for the future.

Physiotherapist Rob Curry, who has practised in remote areas of the Northern Territory, witnessed the experience of an 18-month-old boy who had come home from Darwin hospital after

HealthSpeak

Children with a language impairment are six times more likely to have problems with reading than those without a meningitis infection. The fact that this boy did not have access to a speech pathologist after he returned home from hospital meant that he suffered speech delays from the meningitis and then suffered needless disability. The prognosis is that he will have lifelong problems with learning and communication, and later have problems finding employment.

Speech Pathology Australia says research demonstrates that lack of availability of speech pathology services and long distance travel are barriers to rural people who need these services. There is also a lack of awareness of the capacity of speech pathology services to prevent or mitigate speech and communication problems.

There is no doubt that telehealth would improve access to speech pathology services for country people.

A publication of North Coast Medicare Local

spring 2014

There are services such as telespeech therapy, which use videoconferencing technology to deliver speech pathology services over the internet to those in rural and remote areas, so they are not forced to travel long distances.

According to Speech Pathology Australia, early intervention is the key to preventing or reducing the lifelong implications for many Australians living with communication impairment.

Rob Curry makes the point that it should not be beyond this country or our health system to ensure an acceptable minimum level of service access for all Australians, including people in quite remote areas.

“This is not rocket science,” Rob says. “Remote areas could be broken into regions of similar population size, and then a minimum acceptable level and range of health services applied to this regional population.”

You can see view the NRHA’s submission on the Alliance’s website under Submissions at www.ruralhealth. org.au and more information on the topic can be found on the Speech Pathology Australia website at www.speechpathologyaustralia.org.au

Training to address substance misuse problems HealthSpeak dropped in on the first Substance Misuse Training week run by North Coast Medicare Local (NCML) held at the Lismore Workers Club in June. A total of 35 participants are taking part in the year long training program in Lismore and Coffs Harbour.

NCML Program Manager, Christine Minkov, explained that the aim of the training was to empower people working with clients in a variety of organisations to effectively work with clients presenting with a drug and/or alcohol problem.

“The people training are generalist case workers, so you might have them working in Housing, Juvenile Justice, an employment service, headspace etc. The case workers often find that their clients’ use of substances is getting in the way of them achieving their goals.

Goals such as getting into housing, going to school or finding a job,” said Christine.

Training participants are taught how to engage with the client, screen them on potential misuse problems and work with them using some low intensity Cognitive Behavioural Therapy interventions. These include

From left: Joseph Walker, Balund-a Program; Teri King, headspace; Marie Hainaut, Family Support Network; Kate Binder, The Family Centre Tweed; Tup Moekaa, Juvenile Justice; Jeanette Stockdale, NORTEC; Jude Williams, Family Support Network; Anne Skinner, NORTEC; Samantha James, North Coast Medicare Local (NCML) and Christine Minkov, NCML Program Officer.

identifying that the person has a problem in the first place, goal setting, and identifying the triggers that result in substance misuse.

Christine said she was very pleased with the number of participants from Aboriginal and Torres Strait Islander communities.

Over the 12 months, one day face to face training is also available and will be tailored to

individual needs. Participants also get ten monthly sessions, and individual mentoring offered to one person from each organisation, as well as group mentoring.

“And North Coast Medicare Local is reimbursing participating organisations for the time staff spend away from work so that they may be replaced,” said Christine.

“Basically we’re looking at

improving people’s confidence in working with substance misuse clients, along with their skills and knowledge,” Christine explained.

Trainee Marie Hainaut from the Family Support Network said the training was both intense and very worthwhile. “ I can really see how to use these methods in my workplace and now I’m thinking ‘Why haven’t we been doing this forever?’ It’s so obvious that drug misuse is linked to other life difficulties.

“It will definitely help me in my work to provide proper support to a client when I understand them better,” said Marie.

Jen Stockdale from NORTEC said the program would help her work more effectively with her client base of 12 to 19 year olds.

“I work out west at Casino, Tabulam, Bonalbo and there are a lot of social issues out there. This program explains the reasons behind people turning to substance misuse. There are many factors involved and when you are trying to help someone, it’s good to keep those things in mind.”

For more information, contact Christine Minkov on 6625 0200.

Free professional development for health professionals North Coast Medicare Local (NCML) is pleased to announce that local health professionals now have free access to online professional development through the TAFE NOW website.

As a result of a partnership with the North Coast Institute of TAFE, NCML offers short courses which take about an hour to complete and are worth one CPD (Continuing Professional Development) point per hour.

With NCML’s enrolment key, users will have free and unlimited access to: 1 Allied Health course topics for allied health professionals 2 Healnet course topics for nurses and other similar medical professionals and

3 Generic short course topics for small businesses and self interest All topics are peer reviewed by industry professionals and endorsed by nationally recognised industry associations. Regular topic reviews are also conducted to ensure they incorporate current policies, legislation and Australiawide guidelines.

HealthSpeak A publication of North Coast Medicare Local

spring 2014

Local health professionals can find out how to access the TAFE Now website and start completing online CPD courses by registering with Healthy North Coast at http://healthynorthcoast.org. au/dashboard/signup/ and then visiting the Healthy North Coast Learning and Development Network.

The idea of linking up with TAFE to offer free courses came

out of a survey conducted by North Coast Medicare Local late last year. Participating health professionals said that they considered continuing professional development to be their highest priority.

Armed with this important feedback, NCML broadened its learning offerings to health professionals, providing them with access to TAFE Now. These free TAFE courses complement other educational opportunities provided by NCML such as face to face learning and development events and workshops.

Online learning ensures equal access for all health professionals, including those working in isolated areas to continue to develop their professional knowledge and skills.

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Michael McKay’s Professorship Award Michael McKay, Radiation Oncologist, staff specialist and Director of Research at the North Coast Cancer Institute (NCCI), has been recognised for his work by winning the prestigious Rohan Williams Travelling Professorship Award from the Royal College of Radiologists (RCR) in the UK. The prize includes two return business class airfares with spouse and involves presenting lectures and tutorials at major oncology centres, as well as an address at the RCR Annual Scientific Meeting.

“The objective of the prize is to foster relations between the RCR and the Royal Australian and New Zealand College of Radiologists,” Michael explained.

Recently, Michael reached another milestone in his career, having published over 100 scientific papers.

HealthSpeak visited Michael McKay at the North Coast Institute in Lismore to talk to him about his research and the professorship award.

He has proposed presenting on topics to educate people in the UK in molecular biology and genetics as well as some ground breaking work in breast cancer and radiotherapy.

“I’ll be giving tutorials to the trainees and med students and others. It’s very handy to understand the underlying basis of some of the new pathology tests being done. And there’s been some interest in local medical students learning more about molecular biology too, so I’ll be giving a talk at the University Centre for Rural Health on that

From page 15 from 1976 to 1995 and the Palliative Care Unit at Barraba Health Service was named after him because of the exemplary work he did in the town.

Earlier, Dr Subbiah served as the medical superintendent at Katherine Hospital.

In 2012 he received the Distinguished Service Award

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soon as well.”

Michael’s involved in various research activities at NCCI, including some following on from work he did as Research Group Leader at the Peter MacCallum Cancer Centre in Melbourne since 2000. This involved studying patients who had abnormal reactions to radiotherapy with the aim of individualising treatment.

“If you could select those occasional patients who were adverse reactors, those occasional persons, we could put them aside and then perhaps ‘dose intensify’ the remainder of the people undergoing treatment,” he explained.

This research culminated in a paper recently published looking at how to select patients likely to be bad reactors after breast cancer radiotherapy. Michael said while this research has not yet been externally validated, they were getting closer to isolating a gene signature that would enable clinicians to predict patients likely to have bad reactions after breast cancer radiotherapy.

The NCCI is also working to improve the technical delivery of breast cancer radiotherapy using the prone position during treatment.

“Normally someone lies on their back, but if the patient is large breasted, often the contour of the breast is a bit unfavourable and you worry about ‘hot spots’ and treating more of the important organs underneath than you’d need to. With the prone treatment method, the patient lies face down on a bench. There is a segment of the bench which has been taken out and the breast

from the Australian College of Rural and Remote Medicine.

Dr Subbiah worked as a GP in Port Macquarie from 1995 to 2012 with the Subbiah Family Practice. He was also involved in the introduction of the technique of syringe drive to provide better pain relief to the terminally ill patients, a technique not previously used in NSW.

just falls away from the rest of the body. If the person is physically suited to the prone position which we can tell when we do the simulation scan, treatment can be done with virtually no radiation exposure to the lungs and heart.”

At NCCI, radiotherapy treatment for breast cancer has also been shortened from five weeks to three. Michael is looking forward to putting together research data on the outcomes for patients involved in the shorter treatment spans and the prone position treatment method. That should be available in September next year.

As Director of Research at NCCI, Michael has been associated with getting the work of registrars and trainees published.

He’s also been involved in other clinical studies to be published involving treatment of prostate cancer and brain cancers.

His most recent research follows on from some genes he isolated years ago in Holland that were known to be involved in an individual’s response to radiation HealthSpeak

treatment.

In order to find out exactly what role these genes played, his team created genetically engineered mice with bits of the gene ‘on’ or ‘off ’ to study the consequences in the mammal of those changes.

Michael explained that such work can reflect clinical phenotypes or the effects that are seen after radiotherapy treatment in patients.

One of the mice turned out to be sterile, there was a complete block in spermatocyte development. At the time, the team was collaborating with a group from the IVF Institute at Monash University where they had stored more than 1000 testicular biopsies done on sterile men.

“Some of them had a similar histological appearance to the mice we’d engineered. So we asked whether that gene we’d engineered was involved in the normal progression of spermatogenesis in humans as well. We found a couple of patients with Continued page 30

A publication of North Coast Medicare Local

spring 2014

Registrars have a new champion

Dr Nina Robertson is a North Coast GP registrar and was recently elected as a registrar representative to the RACGP Board.

Amanda Shoebridge, from North Coast GP Training, sat down with Nina to find out about her new role.

Nina takes mouthfuls of her breakfast between questions at a Lismore café where we meet to talk. She needs to make the most of any time she has.

She has met me in a small gap between dropping her children at school and meeting builders at the property she and her husband are renovating. A practicing GP, mother, home renovator and now an advocate for registrar rights – one gets the feeling there’s nothing this woman can’t do.

It was when Nina was travelling in Africa and volunteering in Mozambique in her twenties that she first thought about pursuing medicine. Working together with a couple from Belgium, a nurse and a laboratory technician, her role saw her design health campaigns for malnourished children. It was important work and an intensive six months but Nina felt under qualified.

“Here I was trying to help these people, and I just wasn’t sure what I was contributing. I’d

completed a Bachelor of Arts majoring in Ancient History – such a niche area and it doesn’t easily transfer anywhere. I thought…

I’ve got nothing!”

In the end it was her husband who convinced her to sit the GAMSAT exam after the birth of their first child and Nina hasn’t looked back. She hasn’t had time to.

Q: It wasn’t long after you became a registrar that you jumped into the role of Registrar Liaison Officer with North Coast GP Training (NCGPT) – why is advocacy so important to you?

A: “I’ve always had an interest in advocacy work. I’ve got a very strong sense of social justice and that applies to whatever situation I find myself in. There’s relative social injustice isn’t there? So on the one hand it’s a bit precious perhaps for a doctor to whinge about their pay and conditions, but on the other, if you find yourself in a situation where there are principles that have been violated, no matter if there are worse injustices, it is still an injustice.

“My parents are very social lefty leaning and I really care about health, education, the environment – I believe that we need to work towards a fairer, more just society. I cannot support principles which erode any of those basics, I think they are fundamental and that is the basis from which I start”.

HealthSpeak A publication of North Coast Medicare Local

spring 2014

I believe that we need to work towards a fairer, more just society Q: What challenges do you see facing registrars at this time?

A: “The federal budget has heralded major change for general practice training. The number of registrar training places has increased, however funding for places remains uncertain. I see the increased numbers of trainees as the government trying to convince us of a "more is better" approach - that if there are more doctors, health care will be better, communities will be better serviced. But a “bums on seats” approach is not enough. We need to remind ministers and the general public that general practice is a medical specialty and junior doctors entering this specialty need a tailored, structured, well supported education in order to become competent, independent GPs - and that costs time and money. A failure to commit appropriate funds to GP training may result in erosion of training standards, as providers try to train more doctors with fewer resources. In the long run, this will result in poorer health outcomes for our communities.”

“I really enjoyed my training

at NCGPT – it was of exceptional quality. So it is of primary concern to me that the quality of training be upheld through this transition.”

Q: What do you hope to achieve during your term on the RACGP Board?

A: “To ensure quality of training is maintained and there is a smooth transition for registrars to the new model. We need to advocate for continuity of staffing for training providers to ensure that organisational knowledge is retained. I also believe it is important that the apprenticeship model of training continue.

“I have already been actively lobbying my local MP Kevin Hogan in opposition to the co-payment. This will adversely affect patients, it will mean that GPs and registrars in regional and rural areas who take home a percentage of billings will actually lose money from each consultation and it is therefore a disincentive for GPs to practice rurally.

“Closing the gap on Indigenous health outcomes should be a priority for us all. I also plan to advocate strongly for the fair treatment of Overseas Trained Doctors, and I am committed to ensuring that all GP registrars are appropriately and fairly employed and remunerated.

“It is certainly an interesting time to be on the RACGP Board.

It’s going to be fascinating and I am looking forward to the journey” says Nina.

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Changes to the aged care system On July 1, a range of changes to the aged care system came into effect.

The Federal Government says the changes will give older Australians more choice, more control, and more of the services they might need to stay in their own home for longer.

Changes include: More support for older people to stay in their own home Greater choice and flexibility for how they pay for accommodation and services Transparent accommodation prices and services A new means test in residential care to determine a person’s fair contribution, if any, to their care and accommodation.

New capping arrangements Consumers now have access to information through the MyAgedCare gateway, where people can compare prices and features in the one place. They can also use an online fee estimator for an idea of what they can expect to pay for their care.

Contact: 1800 200 422 or visit www.myagedcare.gov.au

High-intensity exercise and mental health Researchers at the University of Queensland are conducting a study to find out whether high-intensity exercise improves the physical and emotional health of people with mental illness.

PhD candidate Justin Chapman said the study provided an opportunity for people with mental health issues to undertake exercise training in a safe environment under expert supervision.

“People with mental illness tend to face psychosocial barriers to the uptake of exercise and a healthy lifestyle, which may contribute to the poor physical health and lower life expectancy experienced by this group,” Mr Chapman said.

“We know exercise improves physical and mental health, quality of life and general wellbeing.

“However, very little is known about the effectiveness of different types of exercise, or what specific exercise programs suit people with mental illness.”

Mr Chapman said highintensity interval training had

Pharmacy sales of CMs defended The Australian SelfMedication Industry (ASMI) has responded to an Opinion piece in The Australian newspaper which stated that pharmacists should think twice about selling complementary medicines (CMs), in light of the lack of evidence for many around safety and efficacy.

CMs include nutritional supplements and herbal medicines.

ASMI said there was a growing evidence base to support the use of complementary medicines which are taken by two-thirds of Australians.

30

Steve Scarff, ASMI’s Scientific Affairs Director, said that the industry had long argued for appropriate regulation of the sector to help protect consumers and the credibility of those products that are proven and evidencebased.

“Complementary medicines regulation needs to be rigorous, but ASMI works closely with its members from the CMs sector and the Therapeutic Goods Administration to support a regulatory framework commensurate to the risk posed by these products, that protects consumers and

health benefits for people with cardiovascular disease, but this would be the first study of its kind using the training in a mental health context.

“As part of the study, participants will be randomly selected to take part in either highintensity interval training or a moderate-intensity exercise program.

“They’ll complete a 12-week exercise training program supervised by an exercise

physiologist, with three sessions each week.”

Changes in aerobic fitness, physical activity, body composition, cardiovascular health and psychological wellbeing will be measured before and after the program.

“We are also interested in whether or not participants enjoy these exercise programs, and which one is most acceptable,” Mr Chapman said.

engenders trust in the medicines they use,” said Mr Scarff.

He said that sponsors should be able to substantiate any claims they make. There are mechanisms in place to ensure that CMs claims are accurate, balanced and not misleading.

“However, there is room for improvement and ASMI works with stakeholders to ensure this is approached in a measured way,” said Mr Scarff.

He said it was also critical that the Federal Government invest in research to build the evidence base. The NHMRC allocations for research into CMs had been low at 0.2 per cent of total funding over the past 10 years.

HealthSpeak

From page 28 mutations in this particular gene and they were the first cases to demonstrate that that gene could be involved in human fertility as well.”

Michael said it seems there is an overlap between fertility and radiation response and that these genes are involved in mixing and matching genetic material that happens normally in the egg and sperm cells.

They are involved with repairing double stranded breaks in DNA, which happen with radiation.

It was found that those repair enzymes tended to be recycled for the two different processes.

“And nature often does that, there’ll be groups or classes of genes involved with something in the big toe or in the brain, whatever it happens to be, if it’s a similar function that they have to undertake.

So you could in theory think about down the track testing for that type of gene in people who have that type of infertility as well,” Michael said.

And in an exciting development, it turns out that this group of genes are also biomarkers for outcomes in breast cancer and colorectal cancer radiotherapy treatments.

The aim of a great deal of the research that Michael leads is to improve treatment outcomes for cancer patients – to minimise nasty reactions and help identify the best radiotherapy doses for individuals.

NCCI is also reviewing the work of its multidisciplinary clinics to check on the degree of staff compliance around recommendations for treatment and to make any quality improvement changes that will improve the clinicians’ contribution to outcomes.

Congratulations, Michael, from North Coast Medicare Local on your Professorship.

A publication of North Coast Medicare Local

spring 2014

Rising income inequality – do we care?

Income inequality in Australia and most of the developed world has been rising for two decades. The rich have been getting richer and the poor getting poorer. In some cases absolutely poorer.

In countries such as the US, Spain, Greece, Portugal and Italy, it is more pronounced than others. Is this a concern? If so, what is causing it and what, if anything can be done about it?

Well some people care. The IMF, the OECD and a host of noted economists have been warning about a serious problem. For the past three years the World Economic Forum has placed rising income inequality near the top of their concerns regarding threats to global stability.

Other economists are warning that income inequality will lead to higher levels of economic and social instability, slower growth and recessions.

A recent paper from the Australian Federal Treasury on income inequality concludes that in Australia there has been a slow but steady rise in inequality over 30 years. This after taking into account government payments and services that tend to be directed more towards the poor.

But a combination of a progressive income tax system and government services and transfer payments has meant that although inequality is rising in Australia, it is

slower than in other countries.

In the US the change has been much more marked through factors including the GFC. As the free-market Economist magazine recently noted: ‘In America the share of National Income going to the top 0.1% (some 16,000 families) has risen from just over 1% in 1980 to almost 5% now.’ This transfer represents billions of dollars.

And while the wealth of America’s richest has fully recovered from the GFC, the wealth of the poorest continues to decline. In the US, median household income was lower in 2011 than in 1995.

Nobel Prize winning economist Joseph Stiglitz notes that life expectancy of the poorest Americans is in decline, wages are stagnant or falling and social safety nets are woefully inadequate. Why all the concern?

The IMF and others have noted that countries with high levels of income inequality tend to be more economically unstable with slower economic growth. We shouldn’t be surprised at this. If more of the wealth goes to the rich, then the savings rate goes up - simply because the rich save more than the poor.

Now this can be a good thing if the extra savings are put to good use - investing in infrastructure, education or factories.

But higher savings mean less consumption and that eventually

HealthSpeak A publication of North Coast Medicare Local

spring 2014

Real incomes have been falling rapidly over the past 10 years means that good investment opportunities dry up.

After that, all that is really left is unproductive investment (such as asset price inflation - a share market or housing boom) which ends in greater instability, unemployment and recession.

Economist Charles Gave has found that every recession in the US bar one was preceded by a fall in income of America’s poor.

According to Gave, real incomes have been falling rapidly over the past 10 years.

OK, so income inequality is growing. But why has it happened? Opinions differ, but it is no coincidence that income inequality has grown as governments around the world have come under the sway of neo-liberal economic ideology espoused by politicians such as Thatcher, Reagan, Bush, Hawke, Keating, Howard, Abbott and a coterie of sympathisers.

Neo-liberals believe in the supremacy of Mr Market. Allowed free rein, the result they say will be prosperity for all.

Sure the rich will benefit, but so will the poor from the trickle down effect.

Breaking it down, neo-liberals believe in unfetterd free trade, privatisation of government assets, deregulation, cuts in government spending, reduced and flattened taxes, foreign

Economy David Tomlinson

investment, de-unionising the economy and abolishing minimum wage rates. Sound familiar?

This naturally means cuts in social services, big reductions in government spending on health and education, a reduced safety net, cuts in taxes on companies and the rich, an emphasis on self-reliance, a “flexible” labour force and more focus on the individual at the expense of common or shared goods. Some people do well from these policies, others do not.

On the plus side, many people in less developed countries are being brought out of poverty and starvation. On the negative, many are being exploited by a global race to the bottom.

In developed countries the rich are able to take advantage of globalisation while many in the poorer and middle classes are losing. Trickle down does not work.

Global companies now straddle the earth, picking the cheapest labour here, the cheapest raw materials there and locating their “Headquarters” in the country or haven with the lowest corporate tax rate.

There is no room here to go into possible solutions. Clearly globalisation can reduce world poverty but there needs to be recognised that Mr Market is not always right (eg the GFC and climate change inaction) and that there are alternatives to this mad race to the bottom.

Neo-liberal policies need modification. We need to regulate the trend towards increased globalisation by governments investing in people via health and education, adequate safety nets and ensuring the benefits of globalisation and more evenly spread.

Australia has successfully done this in the past - but what of the future?

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Lismore neuropsychologist Keelin Turner has won a SARRAH scholarship to complete training enabling her to use the Autism Diagnostic Observational Schedule II or ADOS-2. Using this instrument Keelin will be able to assess and diagnose autism, Asperger’s and related difficulties.

SARRAH stands for Services for Australian Rural and Remote Allied Health. Scholarship funding is provided by the Department of Health and this national program supports health professionals to train and practice in geographic and clinical areas of need. The scholarships are open to nurses and allied health practitioners.

Keelin said she has wanted to do the ADOS course for some time, but the cost was prohibitive. The SARRAH scholarship for $3000 goes a long way towards paying the costs involved.

Discovering that a local paediatrician was having to send children and their families to Sydney or Brisbane for an ADOS-2 assessments inspired Keelin to apply for a scholarship to fill the gap in North Coast health services.

Currently, Keelin is busy in her private practice mainly working with teenagers with long-term learning disabilities and have fallen through the cracks, but she is keen to expand into working with children with autism.

“Working with kids and families with autism is sort of in my blood. My Mum was the

SARRAH scholarship for Lismore neuropsychologist

Keelin Turner

principal of an autistic school, so when I was young I had friends who were autistic and then I babysat autistic kids when I was older.. I’m very interested in their perspective and how they view the world,” Keelin told HealthSpeak.

She explained how having an ADOS-2 assessment could help a child and their family.

“The paediatrician usually makes the diagnosis but often cases are not straightforward and collaboration is needed and the ADOS is considered by many to be the gold standard. Once a diagnosis is certain, families can

GPs wanted for research project A group of medical students from the University of Western Sydney is undertaking a research project General practitioner management of depression in the Northern Rivers region.

The students have identified barriers to accessing health services in the area, particularly for mental health services. This poses an interesting dilemma for local GPs who have to take into account these factors when making decisions about case management.

In their research, the stu-

32

dents need information from GPs about their management choices, and how these are shaped by the adequacy of, and access to existing mental health services.

It is hoped the published results can be used as an advocacy tool for the community. If you are interested in taking part in this research project, which will involve a 30-minute interview, please contact Kate Sandy on 0400 382 750 Tamishka De Silva, email 17026547@student. uws.edu.au

My Mum was the principal of an autistic school, so when I was young I had friends who were autistic access funding which opens up a wealth of help and support for the child and family.

“There is funding through the Helping Children with Autism package, for early intervention through FaHCSIA or care management through Medicare. The child’s psychiatrists or paediatrician can refer to allied health practitioners who can help with particular difficulties. “ Keelin said that a child on the Autism Spectrum typically struggles at school in coping with the noise and disorder of a classroom and playground. She said they are often overwhelmed and need help with behaviour management focusing on things such as having a quiet space or carrying a bag containing their favourite things which they can take out when unsettled. They also often need programs to help develop social skills and build relationships.

HealthSpeak

“Once the assessment is done, the child can access a psychologist who can work with teachers to develop an individual program for them with methods to calm down and engage with learning and with other kids.

“Kids with autism have speech and communication difficulties, so speech therapists are part of the support needed, and the sensory issues mean that occupational therapists are also often involved, “Keelin explained.

She said that while having a diagnosis of Autism Spectrum Disorder could bring a stigma with it, usually the benefits of having a diagnosis, information about the symptoms, and the community and funding support available meant that it was welcomed Keelin will undertake the course later this year and is already setting up a waiting list for ADOS -2 assessments which she expects to start in November.

She recommends that other allied health professionals apply for a SARRAH scholarship for CPD training as the application was straight forward and not too laborious to complete.

If you’d like to add a name to Keelin’s waiting list for an ADOS-2 assessment, email her at: keelin@nrneuro.com.au More information is available on her website at www.nrneuro.com.au

A publication of North Coast Medicare Local

spring 2014

Roosters in the Ruins The locum agency’s listing for a GP on Norfolk Island stood out amongst the rest, so I took it. All I knew was something about a cruel convict past, and the great Norfolk Pines, so many of which were planted by our forefathers to line the promenade of Australian beaches. In today’s Australia, Norfolk Island is a curious backwater. In early colonial days it was considered vital and strategic.

The ship Sirius, famous from the First Fleet, had become a commuter around the colony, but bad luck wrecked her on the Norfolk outer reef. It was a great tragedy carrying a threat of starvation, saved only by the native flightless burrowing ‘Providence’ birds at Mount Pitt being hunted to extinction.

As locums go, it was an unusual job, with plenty of time off to see the amazing relics of the convict settlement and learn the tale of ‘The Experiment,’ a strange colonisation after the convicts had left.

The island medical practice has an uncomfortable edge in anticipation of disaster. Difficult cases and emergencies carry extra responsibility for the GP because no specialists work here.

Obstacles exist in evacuating patients from the island and not even the most urgent can get out immediately. Add to that a surprising discovery (a leftover of the experiment) that Aussie Medicare benefits don’t extend to Norfolk Island. It’s user pays and no Flying Foctor support either. I heard rumour of a man living on the island with an untreated fractured foot due to hospital costs. According to my source Whiskey was cheaper.

The time warp of Norfolk seems to attract older doctors.

One of the regulars, Doc Martin, is over 70. He can confidently give an anaesthetic and set a bone.

On-call duty is one in three, which sounds a lot, but nights mostly are undisturbed from frivolous costly consultations.

The practice is incorporated in the hospital, a very old-fashioned building set in spacious

grounds. My consulting room has a 1940s era window opening into the garden. The nursing staff are independent and steeped in local knowhow.

From the summit of Mount Pitt, the whole island is an eyeful and takes in great stands of the native Norfolk Island pines.

About 200km of narrow roads and hedges wind around the hills and dales and many beautiful old houses survive.

Norfolk.

Cook was a busy explorer, considering he found it a mere four years after the Botany Bay landing. When Cook saw the pines, he was of the opinion these tall straight trees would be good for masts and spars, so Norfolk became a busy convict settlement, only months after the first fleet settled in port Jackson in 1778.

This was the first of many

Gallows Gate on Norfolk: ‘Last view of paradise from the gate to hell.’

There are no foxes and flocks of wild chooks peck away in paddocks and ruins. Beautiful and free range, they are just too tough to eat, but every day starts with many roosters.

Located 1600 km due east of Cape Byron and closer to New Zealand, it is a wonder how Cook discovered this tiny speck in the ocean, only 8 by 5 kilometres. He arrived during his second voyage in the Resolution in 1774 and named it after his Matron, the Duchess of

HealthSpeak A publication of North Coast Medicare Local

spring 2014

failed enterprises on Norfolk.

The wood was too splintery for masts, but okay for planks. A small ship, the Norfolk was built in this material and used by Bass and Flinders to circumnavigate Tasmania.

In contrast to Lord Howe Island, a suburb of Sydney, Norfolk is an Australian selfgoverning external territory. It does have a NSW postcode but a passport is required for entry.

Quarantine is very strict, so you won’t see any apples and grapes

Light Airs David Miller

Not even the most urgent case can get out immediately

in the shop. In this subtropical zone there are bananas and whatever is in season.

Norfolk Island maintains a strange emotional bond with an even smaller one, far away. The story goes that after Fletcher Christian marooned Bligh and his loyalists from the Bounty into the Jolly Boat, these mutineers sailed Bounty to Tahiti and collected wives, then off again until they chanced upon the very remote hideaway of Pitcairn Island.

The Bounty was burned on the beach to escape the vengeful reach of the royal navy, which eventually turned up to find it overcrowded with religious fanatics, the descendants. These were invited by a forgiving Queen Victoria to settle Norfolk in ‘The Experiment’. Bountyrelated surnames such as ‘Christian’ and ‘Quintal’ are common at the practice.

Prior to this, Norfolk Island had played a harsh role in the convict system, with a reputation for untrammelled floggings and hangings. It is impossible to be unaffected by a ghostly despair evoked by the stone ruins and old cemetery at Kingston Town.

This prison complex is now a world heritage site and rivals Port Arthur in great buildings constructed under the lash, with one difference, hardly any tourists.

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New technique could change prostate cancer diagnosis Magnetic resonance imaging (MRI) has of course been around for many years, but it is only recently that a new form of MRI, multi-parametric MRI (mpMRI), is becoming accurate enough to be of clinical use as an alternative to the prostate-specific antigen (PSA) test and prostate biopsy. And ground-breaking research by two Australian groups published this year may provide the tipping point.

Pokorny et al performed a prospective study comparing transrectal (TRUS) biopsy to mpMRI. To check the mpMRI findings, they performed targeted biopsies of suspicious lesions, and found that mpMRI far outperformed TRUS biopsy, with only 3% of significant cancers being missed by mpMRI versus 28% for TRUS biopsy. As had long been hoped for, mpMRI not only reduced the detection

of low risk prostate cancer, but it also improved the detection of higher risk cancer.

Thompson et al compared mpMRI to a more extensive transperineal biopsy, for arguably a more accurate assessment of the true presence of cancer. They too found excellent diagnostic accuracy for mpMRI. These landmark papers support mpMRI playing a significant role in the diagnosis of prostate cancer, and we should be proud that Australian research is leading the way. However, the results need to be validated across larger multi-centre studies. Until then, many questions remain: Should all patients with elevated PSA undergo mpMRI? Can a biopsy really be avoided if the mpMRI is negative? Can mpMRI be used in active surveillance of men with known low risk cancer?

Therefore there is still some way to go before mpMRI can be

considered the standard of care in prostate diagnosis, mpMRI is currently not reimbursed by Medicare and, crucially, there are currently few practitioners with expertise in mpMRI. It appears that more accurate prostate cancer diagnosis by mpMRI may be just around the corner. The early signs are that this could reduce detection of insignificant prostate cancer and increase detection of cancer most likely to cause disease and death. In doing so, mpMRI has the potential to truly change the face of prostate cancer diagnosis.

Watch this space!

Reprinted with kind permission from Andrology Australia – originally published in Issue 51 of The Healthy Male.

This is an edited extract of Mr Jeremy Grummet’s presentation, “Changing the face of prostate cancer diagnosis and management”, which he delivered to the Andrology Australia Forum in June.

Andrology Australia (www.andrologyaustralia.org) is the centre for male reproductive health, funded by the Australian Government Department of Health and administered by Monash University.

Keeping heart failure patients out of hospital The Northern NSW Local Health District (NNSWLHD) is working closely with North Coast Medicare Local and GPs in an action-based research project to increase the use of flexible diuretic regimens (FDRs) for patients with heart failure.

Chronic heart failure is a major health problem in Australia necessitating frequent admission with health related costs of more than $1 billion per year. Fluid overload is one of the most common causes of hospital admissions for this group of patients.

FDRs have been shown to improve clinical outcomes and admission and re-admission rates. Despite this, we continue to see an increase in potentially avoidable fluid overload related admissions. FDRs are commonly prescribed and managed by specialist heart failure services in large metropolitan areas. However, this is often not the case in regional settings that principally rely on GPs as prescribers. The FDR is a written instruction from a GP advising the patient to increase their diuretic dose in response to 34

weight gains of two kilograms or more. The FDR is written in easy to read language and is incorporated into a Weight Diary for the patient to record their daily weight.

The patient takes their diary to each GP appointment for review. An additional bonus of the FDR/Weight Diary is that it prompts patients to weigh themselves daily and to activate their action plan in the event they experience any early signs of heart failure.

FDRs, in conjunction with heart failure education, symptom management and self-care strategies have been proven to reduce fluid overload symptoms which would otherwise require hospitalisation.

The Heart Failure Liaison Nurse at The Tweed Hospital will educate and review chronic heart failure patients in the community and revise their GP prescribed FDRs on a regular basis either by phone or home visit. Where appropriate, referral to the Heart HealthSpeak

Failure Program is encouraged for closer supervision. This is an 8-week program (free of charge) incorporating a multidisciplinary approach to heart failure education and exercise.

Benefits sought from the project include: Reduction in admission/admission rates for heart failure fluid overload related admission at The Tweed Hospital.

Promoting evidence based practice through increasing the use of FDRs. Improving patient empowerment and self-management.

Improving collegiality and relationships between NNSW LHD, primary health care, North Coast Medicare Local and Southern Cross University.

Referrals to the Heart Failure Program at Tweed Community Health using your local referral pathway and faxing: 07 5506 7510. If you are a Tweed GP and would like to become involved in this project or need more information, phone Fran Leaton on 07 5506 7818.

If you are outside the Tweed District service, contact your local Community Health Centre.

A publication of North Coast Medicare Local

spring 2014

Books with Robin Robin Osborne

The News – A User’s Manual Alain De Botton Hamish Hamilton/Penguin In a predictably erudite review of a Thomas Malthus biography (Australian Financial Review, 4/6/14), Clive James wrote that, “Normality is never news”, and his observation lies at the heart of Alain De Botton’s valuable, and highly readable, new work on the media.

De Botton is a widely published writer whose musings range across Proust, status, architecture and travel. A philosopher with a keen ability to take the pulse of modern society, he has founded The School of Life www.theschooloflife.com - a London-based organisation with an active lecture program and a series of stimulating ‘how to’ books on topics such as mindful exercising, ageing and loving.

Now he delivers a guide to understanding the processes and agendas of the contemporary media in the form of a superbly designed book that is obviously relevant to us all, however we

Briefs

New NR Transport Guide The Northern Rivers Social Development Council has 15,000 copies of a new Northern Rivers Transport Guide to distribute to organisations across the region.

It contains 138 pages of local and regional transport details in a handy A5 booklet. The

guide is available to all community organisations and groups in the region.

To obtain copies for your organisation, phone 6620 1815.

Med cannabis on Norfolk A Tasmanian company has been given the goahead to grow, import and export medical marijuana on Norfolk Island.

HealthSpeak A publication of North Coast Medicare Local

‘use’ the news.

“It doesn’t come with any instructions,” he begins, referring to the news, “because it’s meant to be the most normal, easy, obvious and unremarkable activity in the world, like breathing or blinking.

“After an interval, usually no longer than a night (and often far less; if we’re feeling particularly restless, we might only manage ten or fifteen minutes), we interrupt whatever we are doing in order to check the news.

“We put our lives on hold in the expectation of receiving yet another dose of critical information about all the most significant achievements, catastrophes, crimes, epidemics and romantic complications to have befallen mankind anywhere around the planet since we last had a look.”

De Botton proceeds to analyse “this ubiquitous and familiar habit” in ways likely to encourage even greater scepticism towards the media than we might currently have.

The author divides his focus into the key areas that get the news media’s attention – politics, world news, economics, celebrity, disaster and consumption, echoing the modern-day politician’s common lament that, “The pace of the news cycle is relentless.”

He explains, “However momentous yesterday’s news – the landslides, the discovery of a young girl’s half-concealed body, the humiliation of a once-powerful politician – every morning the

The island’s health minister Robin Adams said growing medical cannabis was a great opportunity for the economy of Norfolk, while providing a much needed medical product for export.

‘We see this as a great opportunity both for the economy of Norfolk Island whilst providing a much needed medical product for export.’

Planting will start in November with the first

spring 2014

whole cacophony begins afresh.

“The news hub has the institutional amnesia of a hospital’s accident and emergency department: nightly the bloodstains are wiped away and the memories of the dead erased.”

On the subject of health news, the title of a sub-section, he canvasses such subjects as the touted ‘miracle cures’ such as green tea, red wine, grapefruit juice and walnuts, and “the underlying, unmentioned promise… that science might one day discover a cure for everything, death included.”

He continues, “Amidst its appetite for murders and explosions, the news remains unhelpfully squeamish with regard to ordinary mortality. Its proclivity for turning death into a climactic spectacle dissuades us from accepting it as a daily reality.

“We are whisked from the bomb site to the smouldering plane crash; we are rarely shown the everyday business of an octogenarian heart giving out.”

Why? Because, as Clive James noted, and De Botton explains in detail, normality is not newsworthy.

Conversely, an obsessive interest in the ‘news’, and too much trust in the way it is presented, is not normal.

Alain De Botton talks as well as he writes – for a taste, see: http://www.abc.net.au/news/201404-18/one-plus-one-alain-debotton/5399498

harvest three to four months later.

Anti STI condom A condom featuring a gel that attacks sexually transmitted infections (STIs) will be on sale in Australia soon.

Australian biotech company Starpharma developed the gel with the hope of reducing the growing prevalence of STIs. Their VivaGel lu-

bricant attacks viruses that cause STIs such as HIV, genital herpes and human papillomavirus.

Laboratory tests have shown the gel can inactivate up to 99.9 per cent of those three STIs. The TGA has approved the use of VivaGel on condoms, and they will be on sale within months. The gel will be used on a new line of Ansell condoms sold in Australia.

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Anyone for the tango?

Volunteers are needed to help with the running of a unique dance course in Port Macquarie.

It’s an Argentinian tango dance course to help those with Parkinson’s disease socialise and improve their coordination The tango classes for those with Parkinson’s and other neurological orders have been very popular. Participants are drawn from the Port Macquarie Parkinson's Support Group and they’ve had fun learning the basics of Argentine tango. Now organisers would like the classes to continue, but they need volunteer help.

They need volunteers to sign in participants on a Wednesday morning, hand out name tags and collect the small hall hire contribution from the dancers. The volunteers would also set

New portal for health care excellence initiatives The Agency for Clinical Innovation (ACI) and the Clinical Excellence Commission has developed an Excellence and Innovation in Healthcare online portal to easily access their initiatives. It’s at: www.eih.health.nsw.gov.au Healthcare professionals, senior executives, clinicians and managers working within the NSW Health System as well as 36

up and clear away morning tea to enable partners to be fully involved with the dance program.

Dance enthusiasts Russell Wilkinson and Sheila MacDougall put the tango course together to meet the needs of those with Parkinson’s disease and volunteered their time to teach the course. But more people are needed to come to the classes and help encourage those participating.

Sheila said Argentine tango improved the balance, mobility and cognitive abilities of people with Parkinson's disease. It improves their brain and their body and there has been an improvement for every person, she said. The program is suitable for those with a neurological condition and partners.

To volunteer or find out more, contact Stuart or Alison Snowden on 6559 4370.

patients now have access to the latest developments.

People can now ascertain at a glance what initiatives are being implemented in their areas and which specific organisations are collaborating and partnering on these initiatives.

There are more than 100 initiatives on the portal, with new ones being added every quarter.

The portal includes a comprehensive search functionality. On the home page there is a list of health networks to access to find out what’s happening in that area, or you can search on clinical topics to find out what initiatives are happening where.

The Women Want to Know project The aim of this national Australian Government campaign is to encourage health professionals to discuss the issue of alcohol use during pregnancy with their female patients.

Australian women consider health professionals to be the best source of information about alcohol use during pregnancy and trust their advice.

For women who are pregnant or planning pregnancy, not drinking is the safest option.

The NH&MRC’s Australian Guidelines to Reduce Health Risks from Drinking Alcohol specify that maternal consumption of alcohol can harm the developing foetus or breastfeeding baby.

For women who are breastfeeding, not drinking is the safest option.

No studies have definitely established a safe level of alcohol consumption and there is no known level of alcohol consumption in pregnancy where no damage to a foetus will occur.

Alcohol consumption during pregnancy may result in miscarriage or stillbirth and may adversely affect lactation, infant behaviour and psychomotor development of the breastfed

From page 19 Retractile: As there is a 5% chance of the testis ascending (acquired undescended testis) sometime before puberty, teach the family how to do the examination and ask them to do it until their boy can do it himself - once a year until puberty (I suggest birthday week as it has something to do with testes). Since the cremaster pulls the testis up at the slightest

HealthSpeak

baby.

In the child, alcohol exposure in utero can result in Foetal Alcohol Spectrum Disorders (FASD) which include premature birth, brain damage, birth defects, growth restriction, development delay and cognitive, social, emotional and behavioural deficits. As the child grows, the social and behavioural problems associated with alcohol exposure in pregnancy may become more apparent.

Intellectual and behavioural characteristics in individuals exposed to alcohol in pregnancy include inattention, impulsiveness, aggression and problems with social interaction.

For more information on the project, go to: www.alcohol.gov. au

excuse, there is no point in putting an ultrasonography (US) probe on the scrotum.

Undescended: There is no point in doing an US. A surgeon will be able to feel it or not. If they cannot, the specificity and sensitivity of US is insufficient to decide on management plans preoperatively. If it is truly impalpable, a laparoscopy may be needed. Ideal time to operate is around 12 months of age.

A publication of North Coast Medicare Local

spring 2014

Wine and good health The benefits of tannins The pairing of wine and food is often discussed and there are as many opinions as commentators on which food goes with what wine. I would argue however that of all the alcoholic beverages wine is the best with a meal, with maybe beer a close second for Asian dishes. And it is the acids and tannins in the wine which make it so.

With this in mind it is worthwhile to look at these tannins.

What are they, you might ask?

Well, they come from the pips and skin of the grapes and the wood of the barrels and are the canvas on which the miraculous art of wine is draped. They are antioxidants which help keep the wine better for longer.

Tannins give you that feeling in your mouth after you have drunk strong cold tea, a not always pleasant astringent finish.

As part of wine however they are appreciated as a textural element, which is why they are often described as velvety, soft, glossy, silken, seductive even. Tannins can also increase our serotonin levels (though this may be the cause of red wine headache for some).

Nature makes these astringent molecules so abundant to help in disease prevention in the bark and fruit and to repel predators.

You will recall how Bayer found salicin in the bark of the willow tree, and no surprise to learn it is found in even greater concentration in the tree’s flowers and fruit. All flowering plants exercise an innate intelligence with these astringent compounds, sending them to the fruit, usually into the skin, to ward off premature ingestion of its seeds.

When the fruit is ripe the plant takes back its tannins and salicin to the trunk, storing them for next season, and on the cycle goes. In this modern era our fruit is often picked under-ripe, so it won’t bruise in travel, and the salicylates are trapped in the skin, which makes for a sharp taste and causes some people grief.

Chris Ingall

Grapes are crushed in the making of wine, sometimes the juice being left to literally run free into the bottle (eg riesling).

When the grape juice is left in contact with the pips and skins of the grapes however, tannins (structure and texture) and anthocyannins (colour) are added, so we have the spectrum from a lightly tinted rose to impenetrable shiraz and cabernets. Even some white wines, so-called orange wines, are left on their skins and stems, the resultant phenolics giving depth of colour, flavour, enhanced mouth feel and again longevity. Part of this colour is due to the presence of tannins. Some varietals, such as cabernet, have thicker skins and their tannic structure can be immense. The great Chateau of Bordeaux uses this to their advantage, creating wines which can live for decades.

So how can this knowledge enhance our drinking pleasure?

Well, we can hold the bottle up to the light to observe if a crust has been thrown, indicating their presence. Wine which has soft tannins or acids from the outset (as do many pinot noirs and chardonnays) means safe early enjoyment, while harsh tannins rarely soften, and like a mother-in-law’s tongue will still be abrasive a decade later. These wines should be served cold to the rellos at Christmas. We also know that firm, layered tannins can ‘soften’ with age, so we can gauge a wine’s drinking window by the type of tannins in the wine. Open a bottle at around three to five years old, and each day on the kitchen bench with the cork replaced is equal to about a year in the cellar. This canvas of tannin allows the fruit to mature at its leisure, adding to interest and harmony over time.

The best way to ensure tannins enhance rather than detract

HealthSpeak A publication of North Coast Medicare Local

spring 2014

from any wine, and ensure its long life, is to pick ripe grapes from ancient vines, gently break the skins rather than press the grapes, and use high quality oak in its maturation. All these suggestions are expensive, but worth it, as these wonderful tannins also enhance wine’s ability to marry so well with food. They react with molecules in meat in particular, so shiraz with lamb, or cabernet with beef are marriages made in heaven.

Harsh tannins rarely soften, and like a mother-inlaw’s tongue will still be abrasive a decade later

Wine Tip

Cellar Tip

Reds which have thrown a ‘deposit’ or crust in the bottle (hold the bottle up to the light) will benefit from decanting. With a steady hand (you may need a shot of brandy to achieve this) pour the wine into a container, leaving about 30 to 50 ml in the bottle. Pour this remainder into a glass, inspect it for residue and discard. Clean out the bottle and pour the wine back in.

The resultant ‘clean’ wine will be softer and gentler to the head the next day.

If a wine is delicious from the outset, it will be delicious as it ages.

Deliciousness is usually the result of balance between fruit, acid and tannic components. Know you can cellar a wine if its tannins create a firm coating on your palate and tongue, a sensation which lingers long after the fruit flavours have left. If it is pleasurable, it will always be so.

37

An Australian Abroad – Rome

Travel

By Alex Lewers

we found ourselves unintentionally walking kilometres, marveling slackjawed at each monument’s beauty.

s of

g wall posin The im sseum lo the Co

38

THERE IS nothing quite like a 32-hour economy class Air China flight to remind you of Australia’s isolation - geographically and culturally.

After waving goodbye to Australia from Sydney’s International Airport, my partner and I set off on the first leg of our European journey en route to Rome.

Twelve hours and three subtitled rounds of the Lego movie The Vatican throng and Robocop later, (nobody told awaiting their audience us there were other channels) we with the Pope touched down at Beijing International Airport.

After being told of the wonders planned to of Singapore Airport, our expectations of a similar have an easy bustling buffet of Asian delicacies and massage day orientatchairs were quickly dashed by what can only be ing ourselves described as Singapore Airport’s ugly cousin. in the city.

At least there would be WIFI right? Well, so Yet, as each long as you didn’t want to use Google, social street led media websites or any other website considered to another potentially ‘dangerous’. monuBefore leaving for Rome we were told to expect ment, we y lost pleasantl s of Getting two things of the city: ne found la d bble in the co 1) To get completely lost and ourselves re Trasteve 2) To have a fight about being completely lost unintenI think in the smart-phone age the idea of betionally ing truly lost has changed, and not always for the walking kilometres, marveling better. However, what we’ve lost in exploratory slack-jawed at each monument’s beauty. romance, we’ve gained with something to blame In just one day, we stumbled upon the Spanish when we do get lost and a reliable point of referSteps, the Trevi Fountain, Palatine Hill, the Colosence for how to get home. seum, and the Vatican. Stumbling upon things has So with our GPS comfort blanket and camera become a recurring theme of our travels. stowed away, we set out to explore Rome on foot Day three in Rome happened to fall on the and WOW did it impress. last Sunday of the month – a free day to visit the If you can put up with the sore Vatican Museums. Fearing half of Rome would feet at end of the day, I would have the same idea, we set out early to find a place highly recommend walking at the head of the queue. around Rome for two reasons: An hour before the doors opened, the line was Italian drivers truly live up to already 600 metres long, and by opening time it their slightly deranged driving snaked over a kilometre behind us. But our luck reputation, and strolling around prevailed and soon we were shuffling with the gives you the opportunity to crowd through room after frescoed room filled ‘lose’ yourself in Rome’s bevy of with Vatican treasures; finishing with the Rabeautiful streets. phael Rooms and Michelangelo’s opulent Sistine We lost hours simply wanChapel. dering through the cobbled Over-stimulated and somewhat overwhelmed streets of our home base of by the cattle crush of people, we stumbled back Trastevere, surrounded by into daylight, and wandered back to St Peter’s multi-coloured, vine-clad Square. housing blocks; hooked in as A sea of people gazing skywards soon quashed bakery and restaurant smells any thought of a quiet rest on the steps of St Pegrabbed our curious nostrils; ter’s. As a voice boomed out across the square we and listening to musical Italrealised, perhaps naively, why there were so many ian conversations (none of people. We had stumbled right into the middle of which we understood). the Pope’s midday mass.

And then there were the After four days in Rome our stay had come to monuments. an end, with our next adventure waiting on the On our first day, we had island of Sardinia.

HealthSpeak

A publication of North Coast Medicare Local

spring 2014

more services · quality facilities

Trivia What is the world’s heaviest lizard and where is it found?

2 What is a group of ravens called?

3 Which two countries sandwich the Dead Sea? 4 What type of creature was Michael Jackson’s pet Muscles?

5 What colour are emu eggs?

6 Which was the first Olympic Games to be held in the Southern Hemisphere?

7 What Japanese war cry meant ‘May you live forever’?

8 What is the only domestic animal not mentioned in The Bible?

9 What is Brigitte Bardot’s real name?

10 How are you travelling in Africa if you’ve rented a rakumi?

11 How many expressways did China’s drivers have in 1992?

12 Which colour appears with blue on the UN flag?

13 What Nepalese city means ‘wooden temples’?

14 Australian Olympic sprinter Shirley Strickland had a specialised scientific qualification, what was it?

15 Which animal is on the Western Australian flag?

16 How many ships were in the First Fleet?

17 What is Kylie Minogue’s lingerie range called?

18 Which of the following is not an Australian innovation? A) Chiko Roll B) Lawn sprinkler C) Plastic bank notes D) Dual flush toilet E) Wine cask 19 What Egyptian city was built up during the Middle Ages from limestone stripped off the exterior of the Great Pyramid?

20 Which continent has the fewest flowering plants?

21 What is the only 100 per cent Christian place on Earth?

22 Who’s known in the shrink business as ‘Weird Beard’?

23 What was the first planet to be discovered using the telescope, in 1781?

24 Who sang the title song for the Bond film The Spy Who Loved Me? 25 For how many years did Britain lease Hong Kong?

1

•Sports & Orthopaedic Conditions •Treat Spinal Pain with mob/ manipulation and Sarah Key Method •Acupuncture for myofascial pain/ muscle spasm •Gym & Pool rehabilitation •Biomechanical analysis for runners and dancers •Orthotics using Gaitscan Technology •Waterproof casts / braces / splints •Vertigo & Balance Disorders Tony Morley & Emile du Plessis and Associates Physiotherapists MAPA

Gabrielle Boyce and Associates 581 Ballina Road, Goonellabah Phone (02) 6625 2888 Open extended hours

OPEN extended hours Goonellabah pharmacy is now open: Monday to Friday – 8.30am to 7pm Saturdays – 9am to 4.30pm Sundays – 9.30am to 1pm

Goonellabah Pharmacy For all your health needs Goonellabah Village, Oliver Avenue Phone 6624 2449

Lismore & Ballina Free Call 1800 662 125

KEEP CALM WORK WITH US AND

Calling all GP’s & AHP who have an interest in the health of young people: headspace Port Macquarie would love to hear from you. Contact Jenny Sinclair on 02 6588 7300 or jsinclair@each.com.au for an informal discussion.

Dr Steven Stylian – Haematologist and Medical Oncologist Byron Bay Specialist Centre, Suite 6, 130 Jonson St

Dr Stylian wishes to announce that he has commenced practice at the Byron Bay address above.

Over the years he has wanted to address the need for specialist care in peripheral regions. He has also remained grateful for his patients travelling to the Gold Coast to access care and now wishes to minimise the need for them to do this. Dr Stylian provides care for all aspects of haematology and medical oncology and specifically provides tertiary level care for complex disorders including leukaemia, all types of malignant conditions, apheresis and stem cell transplantation.

Urgent cases will be prioritised and all patients will be bulk billed. Dr Stylian is happy to provide phone advice if needed and is now ready to accept GP referrals.

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TRIVIA ANSWER 1. The Komodo Dragon, which grows to three metres and lives on Komodo and Rinca Islands in Indonesia.

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HealthSpeak A publication of North Coast Medicare Local

spring 2014

Urgently seeking GP Lismore Family Planning Service Lismore Family Planning offers specialist reproductive and sexual health services. We offer bulk billed services and are looking for a Medical Practitioner to join our clinic. In addition to the Thursday and Saturday clinics at Lismore, there is an option to work at our Kyogle Outreach clinic every second Friday. You should be registered with the NSW Medical Board with current authority and provider number for NSW, and hold the SH&FPA certificate in Sexual and Reproductive Health.

This position offers casual hours in Lismore/Kyogle and above award conditions.

For further information contact Julie on 66201870 or applications@nrsdc.org.au Applications close 9am on Monday Sept 8th.

A/Prof Geoffrey Boyce Neurologist Practising neurology and neurophysiology in Lismore.

Dr Boyce has a full-time neurophysiology technician available to do electroencephalograms with little waiting time. Also nerve conduction studies and electromyography. The practice is Medical Objects friendly and welcomes referrals this way.

Phone the practice on 6621 8245 or email: nrneurol.com.au For more information and links to other sub-specialty groups, view the website at: www.nrneurol.com.au

PATHOLOGICAL WASTE DISPOSAL Container Collection/Exchange

RICHMOND WASTE SERVICES Phone 6621 7431 – 6687 2559 Lismore • Ballina • Casino • Byron

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Care Services

CARE

SERVICES