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Standing Committee on Health - 08/08/2014 - Skin cancer in Australia

McCROSSIN, Dr Ian, Dermatologist

Committee met at 09:03.

CHAIR ( Mr Irons ): I declare open this public hearing of the Standing Committee on Health in reference to the inquiry into skin cancer in Australia. I ask a committee member to move that the media be allowed to film the proceedings today in accordance with the rules set down for committees, which includes not interfering with the committee proceedings and not taking footage or still images of members, committee staff or witnesses' papers or laptop screens.

Mrs SUDMALIS: So moved.

CHAIR: I welcome the first witness. Do you as a witness appearing before the committee have any objection to being recorded by media during participation in this hearing?

Dr McCrossin : No.

CHAIR: Although the committee does not require you to give evidence under oath, I advise you that these hearings are formal proceedings of the parliament and warrant the same respect as proceedings of the respective houses. The giving of false or misleading evidence is a serious matter and may be regarded as a contempt of the parliament. The evidence given today will be recorded by Hansard and attracts parliamentary privilege. Dr McCrossin, would you like to give us an opening statement?

Dr McCrossin : I will just tell you briefly who I am. I am an Australian graduate. I have been a GP in the United Kingdom, Rockhampton, Jindabyne and the Perisher Valley. I have been a VMO in dermatology at the Royal North Shore Hospital and the Children's Hospital. I used to be the director of the STD clinic at the Royal North Shore Hospital. I am now a dermatologist on the South Coast. I am based in Nowra, but I also visit Ulladulla, Batemans Bay, Moruya, Narooma and Merimbula. I go to the Walgett Aboriginal medical service three times a year for two days and to Nhulunbuy once a year. I am also a part-time specialist at Liverpool Hospital. I am a supervisor of training of the registrars there. I do a week a year for the Royal Flying Doctor Service as well. I am a former president of the college of dermatologists. I am the only rural dermatologist to ever be the president. I am still a committee member of the rural and regional services committee and the Aboriginal and Torres strait islanders committee. My interests are dermatology, general medicine, Aboriginal and Torres strait Islander health, and rural and regional services.

The Shoalhaven is quite well serviced for treating skin cancers. There are two dermatologists in Kiama and two in Nowra. There are two plastic surgeons, one of whom is a human dynamo, Dr Harper. There are two GPs with an interest in skin cancer. The radiotherapy unit which has just opened is going to be a big boon to this area—and I can enlarge later on why that is. There are general surgeons as well.

In regards to the terms of references, general practitioners do most of the diagnosis and treatment of skin cancer in Australia. On that basis, they need to be well trained and upskilled if they are Australian graduates. If they are IMGs they may have coloured skin and have had little experience with skin cancer where they come from. Most of the remote general practitioners tend to come from countries where they have had no experience with skin cancer. So IMGs obviously need upskilling once they come to Australia. They also need adequate backup from dermatologists and surgeons in remote and regional areas. When they have reached their limit of expertise they need to be able to do something then.

The problem with dermatologists, like all things with government, comes down to money, unfortunately. We need to retain those we have in regional and remote areas and preferably not upset them, which happens regularly. We regard the Rural Outreach Health Fund—it used to be called MSOAP, the Medical Specialist Outreach Assistance Program—as very important in rural and regional areas. We use that a lot. The funding was cut 14 per cent last year, but I understand its funding is static this year. It has not been reduced. I think we should train specialists from the country in the country. For that, it is important that we have funding for specialist training positions, particularly in New South Wales. We have one on the North Coast, one on the South Coast, one in Orange and another one in Adelaide that is going to the Northern Territory. We regard STP funding as very important for rural and regional areas. We also have a rural dermatologist in New South Wales.

There are a few of us who still bulk-bill pensioners and health care card holders. This is a very poor area, as it is further down the South Coast. As you probably know, the rebates for specialist consultations have been frozen for five years which will damage bulk-billing for those who still bulk-bill in rural and regional areas.

CHAIR: What proportion of lesions that you excise turn out to be cancerous?

Dr McCrossin : I do not keep track of it. I know that there is continual debate about the percentage of lesions which are cancerous but, sorry, I do not keep track of it. If I think something is malignant I will remove it, particularly with melanomas. They argue about pigmented lesions. I would rather err on the side of taking out too many, because a death from melanoma is a horrible death, with secondaries in the lungs, liver and brain and god knows where. So I cannot give you an answer to that.

CHAIR: I was interested in your comment about the IMGs. We have heard in evidence we have taken around the country that various stakeholders concerned with skin cancer are concerned that the undergraduate training of GPs in Australia is not satisfactory and that there should be some more post-graduate courses or some more training periods during the undergraduate period. You also commented about the IMGs. That has been raised before. Would you like to expand on that at all?

Dr McCrossin : With the IMGs it is difficult. The undergraduate training is variable from university to university. My understanding at the moment is that you can go through the whole of the University of New South Wales without doing any dermatology at all. I may be wrong there. They do it as an elective.

It will vary from university to university, so I could not comment on that. From the point of view of IMGs it is difficult for them to come to Australia. They may never have seen a melanoma or a squamous cell carcinoma before. If they are in a remote area they obviously need back-up from that point of view, and training. There are a number of organisations that train people. I do a series of lectures once a year for the remote vocational training scheme, which is federally funded and based in Albury. One of the things we do is look at cancerous and pre-cancerous lesions.

The college of GPs and ARCAM are very active in training people. There is a skin cancer course that the College of Dermatologists runs, where 40 to 50 people every year come along and operate on pigs' bellies and have a weekend on skin cancer.

CHAIR: We have also heard that a dermatoscope is an important tool to use, particularly for early diagnosis. Do you know if the GPs in Nowra would be using a dermatoscope or whether they are trained in using one? Or are they just going by experience?

Dr McCrossin : I think the answer is that some would and some would not. I do not know what percentage would be using that.

CHAIR: What are your thoughts on the dermatoscope? Do you think it is a useful tool?

Dr McCrossin : It has been shown, statistically, that it increases the accuracy of diagnosis for pigmented lesions. Personally, I would rather have pathology. It is regarded as increasing the accuracy of diagnosis—but not to 100 per cent unfortunately. So if you want close to 100 diagnosis—it is not even 100 per cent with pathology—you should use pathology.

CHAIR: In this area of Nowra do you think that enough people have good discipline in getting their skin checked on a regular basis, or do you think a campaign of some sort would improve that situation?

Dr McCrossin : Women look after their health; blokes do not. I think that is a fair generalisation. In regard to skin checks you see woman after woman coming in for skin checks and the blokes have to be dragged in or told to come in by their wives, mothers or daughters or something like that. With the Royal Flying Doctor Service we have these fly-around clinics once a year. Sometimes they do men's health, sometimes women's health. Effectively, in those clinics the dermatologist is used as a lure to get the blokes in. They have their skin looked at and then they are checked for diabetes and prostate and we try and stop them smoking and things like this. So, the women have good discipline but the males are the weak point I would say.

CHAIR: Would that be a cohort across the board or mostly older men?

Dr McCrossin : Sorry?

CHAIR: Would that be across the whole range of men or would there be a particular age group that are less likely to come in and get a skin check. The reason I ask this is because the evidence we have taken is that it is the older generation—50-plus—that are getting a higher diagnosis rate than the lower generation. I am just asking if it is the lack of—

Dr McCrossin : There would be younger men who do not get checked. They do not tend to; they are more gung ho. Unfortunately, melanoma—I cannot give the exact figures—is a significant cause of mortality in younger men after motor vehicle accidents.

Mrs SUDMALIS: From casual conversation with you recently, you were explaining some of the training techniques that you are using for doctors who are coming from overseas. That was pretty fascinating. Whilst there are not many members of the committee here, they can read the evidence. Would you like to describe the process that you used with your teleconferencing to train other doctors?

Dr McCrossin : That is organised by the Remote Vocational Training Scheme, which is based in Albury. They somehow found me and asked me to do it. Initially, it was on Aboriginal and Torres Strait Islander skin disease and then they expanded it. Basically, they organise a group of GPs who, I understand, are trainees from ACRRM and the College of GPs. They are from all over the place. They might be from North Queensland or the Northern Territory. Then we organise, basically, a lecture on the web in the evening which goes for an hour and a half. They are sent all the pictures and case histories, and then you run through them with a facilitator for an hour and a half, and they can ask questions and discuss things, not anonymously but using technology. I think it is a good idea for people who are particularly remote.

Mrs SUDMALIS: The other small conversational piece that we had related to some comments that you had in relation to continuity of the kind of services that come—that when there is a change in policy, you lose a lot of expertise.

Dr McCrossin : Yes. I hope I do not offend anybody. My observation over the years is that the Public Service tends to think in terms of the next budget, which is 12 months away. The politicians tend to think in terms of the next election, which is three years away. The people who I think are most switch on are the Aboriginal ladies in the Northern Territory, who think in terms of the next 100 years for their grandchildren and great-grandchildren. The funding may be cut by 10 per cent. We have somebody who has been doing something for 10 years and suddenly they are handed a contract and the funding has been cut by 20 per cent or you can only work until four o'clock in the afternoon instead of working till 4.30, and they have been doing that for seven or eight years. Then they take umbrage, there is a disagreement and then they say, 'Sod it, I've had enough.' It takes ages to fill that spot again. For the rural and regional areas, somehow we have to persuade doctors who are quite comfortable in their own practice or a big group of six practices in a city to get out of their comfort zone, get on an aeroplane early in the morning and go to an area where they do not have facilities and work. It is very difficult to do. If you lose somebody who has been going for seven to 10 years, it is very difficult to replace them. It may take two years. I do not think the federal government can do a great deal about this because it is usually happening at a state or local level, but sometimes the people doing this think that people are just generic. They say, 'You can go. We'll get somebody straightaway,' but it does not work that way. Sometimes it takes years to replace that person.

Mrs SUDMALIS: I think that this perspective is important to bring forward to the committee because it is totally independent of whoever is in government. It is an important point.

Dr McCrossin : I will find out exactly. Every two or three years, we have a rural and regional meeting for the College of Dermatologists where we start off with one day where we find out what is happening in every state. We get somebody from a particular state to tell us exactly what is happening there. The next one is in October. We have not had one for a couple of years. Then I can find out exactly what is going on. There seem to be problems in Queensland in particular, where they are cutting services. We have just been through a big effort, a few years ago, trying to increase services to regional Queensland—to Townsville, Cairns, Mount Isa, the Gulf and Rockhampton. In some of these areas things have been chopped and it will take years to get them up and going again. I cannot say that categorically because I do not have the evidence for that.

Mrs SUDMALIS: Thank you.

CHAIR: What would be the typical referral pathway from someone being diagnosed to getting to you? Where do they go from you in this area?

Dr McCrossin : I have a very long waiting list in this area. You are talking about time, are you?

CHAIR: No, not about time—just what the pathway would be.

Dr McCrossin : The pathway is the GP refers to me. I don't do so much surgery these days because I have a long waiting list. In this area I tend to refer a lot of people to two plastic surgeons, Warwick Harper and another surgeon. As I said, Warwick Harper is very good. He sees a multitude of people when he comes down here and operates for five days. He also keeps a couple of spots open at the hospital on the public waiting list, because most people here are public rather than private patients. So if there is any emergency thing we think should be done quickly I can ring him up and he will just about always get to them reasonably quickly—within a month. He is very good like that.

One of the problems with the South Coast regional area is that it is a big retirement area and has a lot of nursing homes. If you are working in Sydney you might see a lot of people who are very well and are just having a check, whereas here you get person after person turning up with multiple skin cancers, a pacemaker, on an anticoagulant—multiple comorbidities. So this area needs a lot more resources from that point of view than, say, the inner city does.

CHAIR: Just out of interest, how long is your waiting list at the moment?

Dr McCrossin : It varies. It is months at the moment. It would be about four or five months.

CHAIR: What if it was an emergency case?

Dr McCrossin : My receptionists are instructed to tell people, if they think something is urgent, to ring up their local doctor. As long as the local doctor rings up and says it is urgent, they will be put on at the end of the day. But, because I am the only one who bulk-bills people in the area, my waiting list is long. I think you can get in pretty quick in Kiama and with the other dermatologists here.

CHAIR: Thank you for taking the time off this morning to come in.

Dr McCrossin : I am meant to be at the hospital!

CHAIR: The committee has also heard in various rural and remote areas that there is a shortage of dermatologists. Do you think that is the case on the South Coast? If so, what needs to be done to attract them to this area?

Dr McCrossin : I do not think that is the case in this area here. Further down south, things get worse. As I say, I go to Merimbula and Narooma. It would be good if there were a dermatologist based in that particular area. Also, people tend to go to Canberra from there, and Canberra is a bit of a nightmare at the moment. I think at one stage recently they had all closed their books, after Andrew Miller had a heart attack. We tend to move people from the far South Coast up here to Nowra to get treated, particularly if they are public patients. I find that they will get a better deal here than they will in Canberra. So I move people from Batemans Bay south up to here for the bigger plastic surgery things, to Dr Harper.

CHAIR: So you think you have enough here?

Mrs SUDMALIS: Here we do, but further south we do not.

Dr McCrossin : Further south, no.

Mrs SUDMALIS: That is a five- or six-hour drive.

Dr McCrossin : Yes. So what can we do about it? We have been trying to do something about it for a while. In New South Wales we have set up a rural registrar position, which is regarded as an extra state in the college. When a person applies, they have to put extra information in the application on why they are likely to go to a country area. We are now in our fifth year of that. It takes a while for all this to go through.

I think the first girl is doing her exam this weekend. She comes from Orange and she is likely to go to Newcastle. The next person is in Queensland and he is medically rural bonded, so he has to go to somewhere in Queensland for six years with the MRBs. The next person is from Lismore and our latest girl is a lovely girl from Albany—from your state, Chair. We try to keep these people entirely in the country or in Canberra or Newcastle, where we have problems. They do not get trained in Sydney because we do not want them marrying a girl in Sydney and staying there. They might one year, but most of the time they are rotating through these STP positions. We have STP positions on the South Coast, North Coast, in Orange and in Canberra and Newcastle. We rotate the people through there, so hopefully they will stay in the country afterwards. It is a long-term thing. There is no other way around the problem, really.

CHAIR: What changes, besides budgetary changes which you mentioned before, and the processing of budget changes, do you think could be made to the health system to better treat or support skin cancer and melanoma patients in the South Coast area?

Dr McCrossin : I do not think things are too bad here on the south coast. The major thing would be not cutting the budget things. I think that would be the major thing. We would like to see the STP funding and the old MSOA program continue. We can wear that. I think the South Coast is reasonably well serviced. If you read the local newspapers over a period of time, you will hear people complaining all the time. But in the 30 years I have been here I have never heard a person complain and have never seen anything in the paper about problems with skin cancer management—it just does not happen. As you know, if you read the local papers, you will see something about health every three weeks with something happening. We have very good histopathologists here at Southern Pathology. They are very good histopathologists—better than Canberra, I reckon. So, yes, I think we are well serviced here.

CHAIR: Dr McCrossin, thank you for coming in today. We appreciate you taking the time out of your busy schedule. If you have been asked to provide additional information or if you feel you have further information that could be of assistance to the inquiry, could you please forward it to the secretariat by Wednesday, 21 August. If the committee has any further questions they will send them in writing to you through the secretariat. Once again, thanks for coming along today and giving some evidence.