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Standing Committee on Health - 20/03/2015 - Hepatitis C in Australia

ROESKE, Dr Larissa, Chair, Sexual Health Medicine Network, Royal Australian College of General Practitioners


Evidence was taken via teleconference—

CHAIR: Welcome Dr Roeske. Do you, as a witness appearing before the committee, have any objection to being recorded by media during participation in this hearing?

Dr Roeske : No, I do not.

CHAIR: Thank you. If you have not already done so, can I ask that you please read the document referring to parliamentary privilege. Has the secretariat provided you with that?

Dr Roeske : Yes, and I have read it. I would add that I am the endorsed representative for the Royal Australian College of General Practitioners.

CHAIR: That is great.

CHAIR: Dr Roeske, would like to make a short opening statement to the committee?

Dr Roeske : Firstly, the Royal Australian College of General Practice is grateful for the opportunity to provide a brief submission into the parliamentary inquiry on hepatitis C, and to also be included in some of the discussions today. This is certainly in light of the recent release, of which we are well aware, of the Australian government's forced national hepatitis C strategy. The college would also like to acknowledge the significant personal cost and challenges for those individuals and their families living with chronic hepatitis C infection, and that these populations may well also be marginalised and experience a high degree of discrimination, stigma and shame as a result of living with chronic hepatitis C.

The college also recognises that there is often a significant delay between diagnosis and access to management. Currently a large proportion of those living with hepatitis C are diagnosed and managed in specialist clinics, acute care settings and in specialist general practice. The college would like to acknowledge the importance of prevention and harm minimisation. We see these as key messages for those at risk populations, particularly intravenous drug users and those people that are currently inmates or imprisoned. We feel that GPs can and should play a role in detection, in early detection and in patient discussions about management decisions. We support appropriate safe needle programs in prisons and in other detention centres, and we are very concerned and aware about the fact that being an inmate is an independent risk for having hepatitis B.

We currently have a national specific interest group called Custodial Health, which aims to raise the quality of care and the skills of those general practitioners involved in caring for Australian inmates, and we would very much like to commend this group to you as a source of potential shared information. We feel that there is a great need to raise public awareness through informed education and that we should be including schools, as young people are increasingly entering the pool of those infected with hepatitis C through mainly injecting and intra-nasal drug use.

We would like to also increase the awareness both in the public and for the general practice sector about hepatitis C being a sexually transmitted infection for those men who have sex with men and who are living with HIV. We know that there is growing evidence about hepatitis C being transmitted in this way. We do feel that there needs to be ongoing and continuing regulation and accreditation of tattoo and body piercing operators and operations. We would very much like to support the push for the availability of non-interferon regimes and the new class of anti-virals which will be far safer, more effective and easier to manage than the current subsidised interferon based regimes. We have a pool of S100 trained general practitioners around hepatitis C; however, that pool continues to remain quite small.

We would like to examine and discuss further the possibility or the potential for GPs to become more involved in treating high volumes of patients safely and appropriately, so that we can lower costs of treatment and cut transmission rates. We also would like to support the case for a Medicare item for fibro scan. I think I might leave it there because I have tossed quite a few things forward and perhaps take questions or just be guided by your discussion.

CHAIR: Thank you, Dr Roeske. One of the things that we had listed to asked you is the ability for GPs to initiate treatments for hepatitis C for their patients where appropriate and then refer patients to specialists in more serious cases. You obviously support that proposal. What are your reasons for supporting that proposal?

Dr Roeske : I think a model of comprehensive, continuing care of chronic disease, which is complex, is not an unfamiliar concept to general practitioners. In fact, it forms very much the mainstay of what we are about: comprehensive, continuing care over the lifetime of our patients. We currently use general practices, not just the GP but the practice nurses and the infrastructure of the practice and primary care, to support these patients, who are often from marginalised communities be they Aboriginal and Torres Strait Islanders with diabetes and other health needs through to the everyday person coming in off the street and needing care over their lifetime. We already have existing models of care for complex and chronic conditions. I think from a philosophical point of view and the point of view of what we consider the work of general practice, this is the work of general practice.

CHAIR: What changes would be needed to be made to enable GPs to initiate treatment and what sorts of concerns do you have with the approach that you suggest?

Dr Roeske : For all GPs, there needs to be a perception that this is highly clinically relevant and that there is a clear perception of need, and an awareness of who to target, who the at-risk populations are, so the GPs can actually target, screen and test appropriately. We feel there needs to be more education and a campaign really targeting the general practice sector at the same time you are targeting the public. That needs to be in place and there will need to an upskilling and an education of general practitioners to be able to order appropriate investigations and refer appropriately. That can be done via a variety of means. In order to tap into the general practice sector, the issue needs to be put at the forefront of the mindset. That can only be done by making the need assessment very clear, making it very highly clinically relevant and then really informing GPs how they can target, initially, their testing.

In terms of setting up an appropriate follow-up regime for continuing care and ongoing care, we have done that for a variety of other medical chronic conditions. Hepatitis C will have its own specific requirements. It might be good to try to pilot that sort of an approach in a more mainstream setting. We know that specialised clinics that are doing the bulk of the work. We still might not understand, perhaps, some of the perceived barriers and perspectives the GPs may have around what would work in their practice environment, and also what role the practice nurse could play in supplementing the work that the GPs do.

Mr WYATT: How does the college determine its priorities and what information does it use to ascertain what is a health problem within the Australian community?

Dr Roeske : That is a good question. We certainly have a set of guidelines—for instance, preventive guidelines that cover STI screening and have a particular set of comments and guidelines that are set a standard or a benchmark for what GPs should be doing. These guidelines are usually informed by current evidence and by not just one group but a group of expert bodies. We have a standard-setting committee or group which would look at reviewing standards and endorsing or prioritising certain medical or health conditions over others. So, there is a clear and transparent process that exists within the college framework around setting standards and prioritising, and it has certainly been informed by current evidence coming in from these significant stakeholders or key organisations involved in a particular area or a domain.

Mr WYATT: Given that the prevalence of hepatitis C has been increasing across all states and territories, what has come into the college to alert the college that there is this growing problem that is compounded because of the way in which hepatitis C is being either treated or treated with scant attention?

Dr Roeske : I think what would come into the college would be something like this, for example: there are various organisations, groups and associations that will contact the college with a particular issue, such as a health issue, that might be of concern. The college will be aware of what is in the media, to a degree, and what sort of public health campaigns are ongoing. In terms of how it actually sifts through that and prioritises it, I cannot answer that question. I would be happy to get back to you about the details of that process—because I am not part of the standards committee. However, something like what we are engaging in today would mean that I as Chair of the National Sexual Health and Medicine Network. would actually go back and provide feedback to the college. I would also act and have the ability to alert the college to a need, a pressing need or an emergent need.

Mr WYATT: Given your key role—and it is an important role—what consideration would now be given to a model of care for those with hepatitis C in Australia, taking into consideration urban, rural, rural remote and remote areas?

Dr Roeske : I think that is a very good question and I think that you have highlighted something quite important, which is—and I had a look at the literature and the research pertaining to Australian general practice—that I am not aware of a model of care that has been trialled or piloted for mainstream general practice that would be reflective of the diversity of general practice, or, in another way, that would be more reflective of those practices that do not have high caseloads or are not diagnosing or managing many of those who have hepatitis C. That would, I think, be an aim, and the college would probably consider looking at possible models of care, what would be considered best practice and what would be achievable within a standard general-practice environment.

Mr WYATT: How do stakeholders engage with the college? If there are significant stakeholder groups in various jurisdictions that have a strong interest in this, including people living with hepatitis C, how to they engage with the college to influence the college's thinking and the way in which the college engages GPs across the nation?

Dr Roeske : With relevance to hepatitis C—and I will take this feedback back—I would encourage contact with, particularly, the three main groups of specific interest and expertise that are supporting mainstream general practice. So the custodial health group, the Addiction Medicine Group—they are actually not groups; they are networks with significant memberships and their brief is really to improve the quality of care and the expertise in that particular area of health—and the Sexual Health Medicine Network. You are speaking to me currently, but the chairs of the other two groups would be paramount to engage with. It is through these groups that we are able to redefine an approach to educating the general practice sector or be more proactive or actually feature an issue or a health concern more prominently and highlight it, if you like, for our members. That is one way, and the other way is to provide either written or verbal feedback to the college. I might actually have to clarify for you where and who would be your main contact points at the college for that sort of thing. I am sorry I am not able to provide you with the specific details now.

Mr WYATT: If you could forward that to the committee, that would be tremendous. I will hand over to another colleague, even though I have got plenty of other questions to ask you.

Mrs SUDMALIS: I am curious: one of the previous presenters said that there are about 15 per cent of people who are likely to have hep C who are actually not diagnosed. How can the college get involved in that and increase GP awareness? You did mention earlier—there are two parts to this—that the college has a committee that puts together standards. How does that translate to the general practitioners themselves?

Dr Roeske : I will take that part first—the standards are published in an online or a PDF version. Preventative guidelines are available to all of us as part of our membership of the college, and they are accessible online at any moment. We often refer to them when we are trying to make clinical decisions. They are designed to be accessed pretty simply and quickly, even in the context of our day-to-day work, but they are also available to us should we choose to look at them in more detail at any time. There is unrestricted access for college members to this sort of material. It does then rely on the general practitioner to engage with the resource. They are made aware that these resources are available to them, and it is a part of their membership.

The other way we ensure that GPs continue to be well-informed about important issues is through their own undertaking of professional development, which is a three-yearly cycle and has quite a rigorous expectation of attaining points over a triennium with two very high-level activities that often—I am drawing these to your attention because I believe that designing activities like these, which are designed to change the behaviours of GPs and also allow them to self-audit their own performance or the performance of their practice, around a particular indicator or an auditable outcome is a way to engage general practitioners. These educational activities would be available to GPs and advertised quite proactively in the various publications the college produces as well as online, and as well as a CPD calendar. It relies on the GP to make an individual choice to engage with an activity. We know, because we do a lot of work developing that sort of educational activity, and I have experience in that area, that GPs will engage with an activity if they perceive it to be highly clinically relevant. They actually see that as being of more benefit, or more interest to them, than whether it is convenient, online or even timely. If it has got high clinical relevance, we find GPs will engage with that sort of activity.

The college has a number of conferences and academic sessions which it runs. The big conference is usually the GP conference, called GP15, in Melbourne this year. Our network will be trying to feature a section on hepatitis C, for instance. But again, it will be only those people that register and attend that will be able to take part or learn some skills. The variety of avenues around educating GPs needs to consider the appeal of clinical relevance and look at activities that actually permit self-reflection, self-audit and that would encourage behaviour change.

For GPs to test more patients, they need to firstly understand why they need to test more patients. There needs to be a perceived need; why is it necessary? Then who do they target given their busy schedules? So how is it most effective to actually target and test patients? Should they be offering it to everybody or should they be offering it to a select population? How do they select? How do they make that risk assessment? They actually need to be given the skills to do that. They need to be taught how to do that.

Mrs SUDMALIS: If you have some available copies of the educational material that you use to educate the doctors on hep C, is it possible to forward links or information related to that?

Dr Roeske : Yes.

Mrs SUDMALIS: From what I understand from the information you just gave is that attending the conferences or doing the courses is actually up to the doctor to self-initiate for self-education, which means that their awareness is already established. When we are looking at a disease that is a chronic and increasing incidence disease, perhaps there needs to be a more proactive approach taken by the college to alert more GPs to go through that process.

Dr Roeske : Yes. I think there is definitely a case for a greater and more proactive exploration in the initiation or involvement. But that also needs to be considered in the context that currently many GPs cannot, for instance, access or would not feel that they may be skilled enough to manage or care for those who are needing particular management or treatment for hepatitis C. So there is a barrier there which has been there for good reasons historically.

We are at a time of potential change. If it was in fact the case that new medications were to become accessible to all GPs to prescribe, we would have a higher effective cure rate and a lower complication rate. I think that would be of great interest to the college and to GPs. I think that also needs to be considered in that equation of preparing a general practice workforce or educating a workforce or retraining a workforce or changing the mindset of a workforce. It would seem wise to be doing that with that future view.

Mrs SUDMALIS: Thank you. I will reserve another question for later.

Mr WYATT: Doctor, I am interested in your conference because I know, having worked in Health, they are extremely helpful for GPs. In the lead-up to the Melbourne conference, would it be possible for your organisation to highlight this inquiry and encourage some of your membership to look at the submissions that have been made to the inquiry because a number of them make references to their GPs? It may be an informative basis, and then that may pique the interest of a number who will then want to attend a session on hep C.

Dr Roeske : I have taken note of that and I will actually approach the conference organisers, obviously, and ask them that question. I think it is a very good suggestion. There is much that can be done, as many of you would appreciate, often even by one person or a motivated individual. I would also like to approach my colleague chairs of addiction, medicine and custodial health, to see if there is something that we can work on together to offer general practitioners, in the light of possible changes to the new medications and the new way of treating but also in the light of what we understand is this increasing burden. What I am saying there is there is also every possibility that after today I can sit down with the chair of addiction medicine and the chair of custodial health and say 'Can we put something together and create an audit activity or educational activity, a set of webinars, a conference, or even a booklet or something to upskill GPs and support them?' There are many opportunities. It goes right back to the training of our registrars. We can design exam questions around hepatitis B. We can incorporate cases in the training of upcoming GPs; rotations that would allow exposure and expertise to be built. So there are many areas that we can come in at GPs, so to speak, to increase their knowledge, their confidence and their skills. I will most definitely speak to the GPs' 15 organisers and conveners and get back to you—you will just have to give me a way to get back to you, that is all, because I need to get back to you on a few things.

Mr WYATT: I just want to compliment you on that, but I would certainly be interested in what your custodial chair has in the way of thoughts, because it is an area that is perplexing not only to the committee but certainly in terms of some of the key stakeholders, about the rates of hep C within prisons, and the way in which we need to think of treatments, and whether you have a needle clinic within a prison would be worth mulling over. The other more important question I want to ask you is—we did a previous inquiry into overseas trained doctors who are here on 457 visas. In states like Western Australia, where 49 per cent of the rural medical workforce are OTDs, that would be somewhat of a challenge in providing some of that information to them. Given we are hearing evidence that there are high rates of hep C within Aboriginal communities, that requires another strategy in the construct of our thinking.

Dr Roeske : Yes. We do deal across a number of different health issues with trying to get messages out to GPs across the nation, so to speak. There are already in place some very good ways to reach GPs. We have the ability to work with people online now. The NPS is a great example of providing really good education with actual high-level auditable behaviour change activities incorporated that has a nation-wide reach. There is great work being done to support GPs around hepatitis B, both hepatitis B Victoria, that I am familiar with; also ASHM, producing diagnostic tools and referral tools that are available, again, to GPs.

We have a group of specialists within our college looking particularly at the needs of Aboriginal Torres Strait Islander people. We know that hep C is a disproportionate burden in those groups. I must admit that is probably not an area of my own expertise, but it something that I would be pleased to raise with that group within the college. I cannot comment on the sorts of activities and education they would be doing around hepatitis C for ATSI populations, but I am happy to look into that. But I am sure that they will be doing something.

Mr WYATT: If that is the case, and they are doing some work, it would be helpful to the committee if they had a short statement indicating how they are working on that issue but, importantly, how they are engaging with the Aboriginal community controlled health organisations. In rural and remote areas, people tend to rely on the ACCHOs.

Dr Roeske : Yes, they do, much more so, and we are aware of that too. The whole approach needs to be very culturally appropriate in order to engage ATSI people in the health system. So you are interested in not only a short statement on the work that they are doing but how they are engaging and working on this issue with those relevant organisations, the ACCHOs particularly.

Mr WYATT: Also, given a number of ACCHOs have a higher rate of OTDs working in their practices, I think that is an important element as well.

Dr Roeske : Yes.

Mr WYATT: I have no other questions. Thank you for your frankness.

Dr Roeske : Thank you. Could I ask a question?

CHAIR: We will let you ask it.

Dr Roeske : Thank you. The question is, just for my purposes and also to keep track of what I said I would explore further and get back to you on, will I be provided with a transcript or something to keep track of our conversation and our discussion today?

CHAIR: Yes. It is being recorded by Hansard, and the secretariat will forward you a copy of the transcript if you would like to check it for accuracy.

Dr Roeske : Lovely—thank you very much.

CHAIR: Dr Roeske, thank you for giving evidence today. If you have been asked to provide additional information, could you please forward it to the secretariat by 2 April. If the committee has any further questions, it will send you these in writing through the secretariat. But, if you feel there is other information we need, please feel free to forward it. Again, thank you for your time today.

Dr Roeske : Thank you. It is my pleasure.

Proceedings suspended from 10:42 to 11:01