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Standing Committee on Health - 06/06/2014 - Skin cancer in Australia

ARNOLD, Mr Chris, Executive Director, Skin & Cancer Foundation Inc.

BAKER, Associate Professor, President, Skin & Cancer Foundation Inc. and Director of Dermatology, St Vincent's Hospital

MONAGHAN, Mr Peter, Director, Corporate Affairs, Skin & Cancer Foundation Inc.


CHAIR: Do you, as witnesses, appearing before the committee have any objection to being recorded by the media during participation in this hearing?

Mr Arnold : No.

Prof. Baker : No.

Mr Monaghan : No.

CHAIR: These hearings are formal proceedings of the parliament. The giving of false or misleading evidence is a serious matter and may be regarded as a contempt of parliament. The evidence given today will be recorded by Hansard and does attract parliamentary privilege. Thanks for coming along today. Would you like to make a short opening statement for the committee?

Mr Monaghan : You have our submission in front of you. I would briefly like to say that we provide treatment, we conduct research and we provide education in skin health, skin cancer, melanoma. We would probably provide some 27,000 patient treatments a year. We do about 5,000 surgical procedures per annum. Most of that is in skin cancer.

On the education side we provide the CPD for dermatologists. We provide the training for registrars in dermatology. We do that on behalf of the College of Dermatologists. We also provide education workshops for general practitioners. We also have a public education program. On top of that, we conduct a large amount of research. Indeed, in the submission I have provided you I have indicated that we have published and presented some 60-odd papers in the last 12 months. I think that credentials us as being the largest centre of excellence in dermatology in Australia.

Mr Arnold : I would like to pick up from Peter if I may. I have a quick comment following from the previous speaker. The foundation has been very actively involved in the World Congress on UV and Skin Cancer Prevention. Next year Melbourne will host that particular conference. The first two years have been in Europe, and we have been part of the organising committee for each of those events. We certainly will be, next year. As Peter mentioned, we really are at the forefront of involvement in skin cancer and skin cancer prevention. We are also on the Victorian government's skin cancer prevention framework committee.

I just wanted to focus on three things in our submission today and talk a little more about them. The first one was about our major recommendation suggesting that the Minister for Health establish a multidisciplinary UV and skin cancer prevention committee. Our view is that the treatment and the involvement needs to be multidisciplinary. Dermatologists play a very major role in the identification and training, which I will come back to in a moment.

We feel the existence of an on-going committee can do two things. Firstly, it can ensure that there is input from various groups—dermatologists, oncologists, radiotherapists et cetera and allied health. That can be a melting pot for policy development that can be overarched by the federal government. Secondly, having had that information, it can be a source of communication out to the media. Really we say that if you have this expertise there why not use that as a vehicle for key messages to go out to the community in terms of skin cancer and UV. That was really the first one, and, given, as Peter mentioned before, our strong involvement, we would be absolutely delighted to be involved in such a group if it was set up.

The second one really is around training. Certainly, the Australasian College of Dermatologists is the lead body in the training of specialist dermatologists in the country. We in the foundation are very active participants in that, and all of Victoria's registrars spend about a quarter of their four years going through the foundation's 25 different subspecialist trainings programs. We provide a home for all of those 30 dermatologists in training at any one time. We also train international medical graduates. The other element which we think is very important is around GP training. We believe, as I think you would have seen from the Royal Australian College of General Practitioners' submission, that the first port of call is, if someone has got an issue, to go to the GP. We do not believe that they should be coming straight away to a dermatologist. The GPs, with their ability to take a general history, understand the familial background et cetera, should be the first port of call. So we have taken the approach that we believe we should be involved—and are involved—in the training of GPs. GPs, as you probably know, get about 1½ hours training in dermatology in their undergraduate course.

CHAIR: That is what we have heard.

Mr Arnold : We have taken a very active role in working occasionally with people like Monash University to run skin health and dermoscopy programs and, in our own right, we have run a series of workshops on skin cancer over many years.

Ms HALL: Just on that 1½ hour training, what do you think is the appropriate level that should be given in the training?

Mr Arnold : I would probably defer to Professor Baker for that.

Prof. Baker : I think undergraduate training is a key area of teaching our young doctors about skin cancer in the context of dermatology. They get a little bit of skin cancer training in their surgical terms, but it is a drop in the bucket when you compare their overall medical degree and the size of the public health issue. To answer your question, I do not know what the appropriate amount is but it is a lot more than they are getting at the moment. There is always a battle for space in undergraduate programs. You have got the cardiac surgeons and you have got all sorts of other interest groups that are trying to grab time. It is a balance, but at the moment dermatology and skin cancer teaching is unrepresented.

CHAIR: We heard evidence in Queensland that a lot of GPs did not have the dermatoscope and that the ones who did had a far better success rate in diagnosing.

Prof. Baker : The dermatoscope is a tool, and I suppose it is like giving a tool to a tradesman and saying you are going to be a better tradesman if you have this tool. You have got to be trained in it, and it has to be taken in the overall context of training. So I probably would defocus from the dermatoscope, but I know what you are getting at.

CHAIR: But part of the picture was that those who had done the extra training plus had the dermatoscope were far more successful.

Prof. Baker : Yes, and there are courses that upskill GPs in the use of the dermatoscope, which is great, and I totally support that. But there is a risk of focusing on one modality. There is a bigger picture there.

Ms RISHWORTH: I just wanted to go to something you specifically said regarding people that came to their GP first. We have had discussion about a national screening program to identify it before, and we have heard evidence for a national screening program where you regularly come every two years. If the GPs do not know very well when someone presents, how are they possibly going to know when someone has not presented but try and identify it before? We have heard that men do not really present et cetera. Is that part of the training that you are talking about?

Mr Arnold : I think you have raised two questions. One is around the training of GPs and the other is around public awareness. I am very happy to comment on both.

Ms RISHWORTH: Probably around the GPs, but feel free to comment.

Mr Arnold : There is no doubt that, as Professor Baker mentioned, there is an absolute need to increase the training for GPs. I think it goes without saying that we as a foundation are trying to increase the amount of time we are putting into that. A comment I was going to make a little later when I talk about technology is that we are currently engaged in discussions with the Royal Australasian College of General Practitioners to look at the use of technology to videotape education sessions and have a GP with the expertise. We have very good relationships with the college of GPs. One of their education committee has actually done one year of dermatology training with us at the foundation. So he was very keen and has been working with us to look at how can we over a period of time come up with a training program that would enable modules to go up online for GPs to increase their expertise in both skin cancer and dermatology generally.

We definitely need to see more and more training of GPs but it should be led by dermatologists who have done the four years of specialist training. Our concern would be that you really need an expert group; a plumber trains a plumber's apprentice; you do not have somebody else training a plumber's apprentice, and the same deal applies.

Dr SOUTHCOTT: I would like your view on what is the optimal division between the roles the GP can do and the roles that the dermatologist specialist can do.

Prof. Baker : Andrew, you really nailed it there. The GP is the doctor who has the holistic view of you. They know your medical history; they know your family history. They know your past history. They are the coordinator. They are the conductor of your care. They need to be skilled enough to be able to do some screening and perhaps deal with most of the common issues. There is no way that dermatologists or surgeons are going to deal with the vast amount of skin cancer that we have to deal with in this country. So they must be upskilled; they must be trained. But they are in the very special position of being able to see the overall picture of the patient. Picking up on your point about screening, I understand where you are coming from there, because this might be one of the directions we take in the area of the breast-screening programs that are around. That may be a very valid area to look at and it may be a very good way of allocating resources, but it is not going to be a program in isolation to the GP. In fact, a bit like breast-screening, the patient may go and have their analysis with a report back to the GP. So that might be one model of how this could work.

Dr SOUTHCOTT: Just so I am clear, in your best practice, GPs can do biopsies and simple skin excisions, but best practice would also be that they have had some training, which is available through the RACGP, which you deliver, so that they have special skills in that area.

Prof. Baker : I think that would ideal. Not all GPs want to do these procedures, but in multi-GP practices you often find that one or two GPs have an interest in that area. That is ideal, so long as they are getting the training from a source that has credentialling in the area to provide the training.

Dr SOUTHCOTT: Also, the GP would have a certain role but they would also know when to refer on as well.

Prof. Baker : Absolutely. Training is all about knowing what you know and what you do not know and when to stop.

Ms RISHWORTH: And when would that be—that point to refer on?

Ms HALL: Sorry, I have steered you off topic.

Prof. Baker : That is perfectly fine. Actually you have drawn out a number of points we were going to make.

Ms RISHWORTH: So when is that point? Is it when it comes back as problematic and then you go to the dermatologist? When is the point that, for most GPs, it would be advisable to refer on to a dermatologist?

Prof. Baker : I think that is going to vary from GP to GP.

Ms RISHWORTH: Of course.

Prof. Baker : But essentially it is going to be patients who are high risk or who have difficult tumours or who have a particularly positive family history, for example. So there will be groups where it will be automatic that a patient needs referral; there will be other instances where there are one or two lesions that can be easily managed.

Dr SOUTHCOTT: What is the relationship between the foundation and the college of dermatology? You said you are contracted to do some things for CPD for the college.

Prof. Baker : Yes. It is an interesting thing. We all wear multiple hats in this world. I am the president-elect of the college of dermatologists.

Dr SOUTHCOTT: Congratulations.

Prof. Baker : And current president of the Skin and Cancer Foundation. But the Skin and Cancer Foundation in Melbourne—and there is one in Sydney which I believe you are hearing from—is a group that was put together by dermatologists to promote training and research and to provide special services. They are not-for-profit private organisations. But the membership of the foundation is mostly college of dermatology fellows. You are right that a lot of training of dermatologists is conducted through the Skin and Cancer Foundations, but they are separate entities.

CHAIR: Thank you. Mr Arnold, I invite you to continue with your opening statement.

Ms HALL: Sorry, I just wanted clarification.

Mr Arnold : Thank you. The other clarification I want to make is that the college sets the standards for education and does the assessment. As Chris said, we provide a service in providing the sorts of clinics that they get experience in and so forth to then sit their exams.

The last point I really wanted to tackle was around the use of technology. There are two areas in technology which I think can help. The base line is that there are only about 600 dermatologists in Australia and about 130 of those are in Victoria. Many of them are around capital cities. There are very few people out in rural and remote areas. You would be aware that Medicare currently funds what we would call teledermatology or telehealth, where a GP will take a photo of a particular lesion or a condition, fill out a template and send that to a dermatologist. The GP and the patient will be at one end and the dermatologist at the other, and there will be a videoconference. This happens in other specialities and that is currently funded.

There is before MSAC at the moment a proposal where you can in dermatology, and to some extent in ophthalmology, set aside having a videoconference; the image and the template go to the dermatologist, if they feel comfortable—and I would say that the gold standard is face to face with a patient, so we are talking about a dermatologist being comfortable that they sufficient information to be able to make a diagnosis using technology, so that they can then write the report and go back to the GP and say: 'We think this is an X; do Y'.

We believe that the use of technology in that area can absolutely increase the ability of GPs in rural and remote areas to have access to qualified dermatologists. And the same applies to aged-care centres because it is extremely difficult to get any specialist into aged care centres. In both those instances, we believe the use of technology, under guidelines set by the college, is a very useful adjunct and will improve both the diagnosis and the overall quality of life of people who develop either skin cancer or melanoma.

That was the first phase of the use of technology. The second—I mentioned it before so I will not go over it again—is using videoconferencing and web streaming by webinar of education sessions that are being undertaken by groups like the foundation. We already do this with a number of our registrars and trainees. And we have a program that we are hoping to roll out over the next 12 months where we can do more of the sorts of sessions we are doing at the moment and have them available for GPs and to some extent to dermatologists and registrars in other areas of the country where these training opportunities are not available.

That was really all I wanted to add. I think Professor Baker had a couple of points to add to what he said before.

Prof. Baker : Thank you. I will keep it brief. There were a couple of other points that I think are relevant to this inquiry. One is the public perception of and confidence in the doctors they are going to see. I come back to the role of the GP—and you will hear this from the college of GPs and others. There is clearly a need for skin cancer clinics—that is, clinics that are set up specifically to look at skin cancer patients. There is clearly a need for this type of service. The issue in our minds is the perception the public has of these clinics as to their degree of specialist training and whether they are holding themselves up as specialists now. I am not saying they are not doing good work but I think one of the outcomes of this inquiry or subsequent inquiries ought to be to clarify in the patient's mind and the public's mind who is doing what for them and what their level of qualification is.

Mr WYATT: Do you want to expand on that? I want to come to a question about nurse practitioners. In many instances across the nation the ratio of GPs per 100,000 of population is problematic even in some capital city areas; accessing a GP or where GPs charge a high rate for a visit. Then the public contact becomes less, and often emergency departments are used as a de facto. The establishment of nurse practitioner practices is seeing people seeking them out before they seek a GP. How do we look at combining the skills of people within the health profession as opposed to siloing expertise?

Prof. Baker : I do not think it is so much siloing expertise; it is more about the public having an accurate understanding of who they are seeing and understanding the level of training of the person they are seeing. APRA is quite clear that a specialist must be a member of an accredited specialist training body or have qualifications from a training body. I will not spend too much time on this, but I think there is an issue of the public believing they are seeing a specialist who may or may not be saying they are a specialist. It is important that they understand that, for example, it may be someone with GP-level training who has an interest in skin cancer. That is absolutely fine as long as that is declared upfront.

In answer to your question, this is really a workforce and manpower issue; how do we address the clinical problem? Indeed, there is a role for upskilling nurse practitioners. We are dealing with that in dermatology in different areas not just in skin cancer. At the Skin and Cancer Foundation, our body of nurses are receiving extra training in areas and are undertaking independent practice in certain sections. I think you have hit on an area there which is certainly worth exploring. It is probably beyond the scope of our report, because there are training and credentialling issues involved. But it is certainly worthy of exploration.

Mr WYATT: I ask that because we have many rural towns across this country of ours that only have a nurse; they do not have access to a GP. In rural and remote communities, in Indigenous communities, there is a community health nurse that provides front-line services. In all those communities you get people with skin types that are highly vulnerable to skin cancers; the nature of their work takes them there. How do we address that in your view?

Prof. Baker : Getting back to the nurse practitioner, I suppose it is the level of independent practice and this leads back to training—

Mr WYATT: I am talking about community nurses now.

Prof. Baker : I think this meshes in with Chris' comment about the introduction of technology. What could be better than having a nurse who has had some additional training in skin cancer identification and full skin checks, with access to technology that allows them to send images back to a specialist or the GP? It is an ideal way of addressing the geographic challenges we have in the country.

Mr WYATT: Also access to telemedicine is problematic; so you have another issue there. That will do for now.

CHAIR: Ms Hall?

Ms HALL: I firstly want to touch on the point you made about the GP clinics. I think each and every one of us would have numerous GP clinics set up throughout their electorates that advertise or promote themselves as skin cancer clinics. What do you think needs to be done around that space? You talked about making sure that people who attend them understand that in the majority of cases they are GP clinics. Do you think that there needs to be some regulation around that, or that better information needs to be put out there, so people in the community know what they are getting?

Prof. Baker : I understand where you are coming from. I think it is an issue of the public knowing what these clinics are, what they can do and what the level of training is. As to regulation—

Ms HALL: As to how we can facilitate it in any recommendations that we would make as a committee.

Prof. Baker : I suppose it would be through formalisation and recognition of training programs. There are a lot of little programs and diplomas and degrees that are out there.

Ms HALL: In a lot of these clinics, the GPs have undertaken that training.

Prof. Baker : Indeed, but they are not credentialed. Good on the GPs for wanting to up skill and improve, but perhaps we need some regulation around the training program and credentialing of these programs.

Ms HALL: So maybe putting in place some regulations or whatever saying that you cannot promote your service as being a skin cancer clinic unless you can tick these boxes or something like that.

Prof. Baker : That may be one way of going about it.

Ms HALL: You are the experts. I am not the expert. I am turning to you for you to give us guidance.

Prof. Baker : I think a lot of these questions are probably better addressed with a college hat and with the discussions between the College of GPs and perhaps the groups that are credentialing the training programs. I am not deliberately dodging the questions; I do not have the answer. I think it needs to be worked through in a way that will be fair to everybody, but also have the outcome of certainty and confidence for the public.

Ms HALL: When I say that, I think there are fantastic GP clinics offering that skin cancer care. I am not in any way having a go at those, but it is about making sure that people who visit a clinic can have some certainty.

Prof. Baker : Have some confidence, exactly.

Ms HALL: The other question I quickly wanted to ask was about occupational health. I see that one of your recommendations—recommendation 4—says that the ACTU be encouraged to replicate the Victorian Trades Hall Council's skin cancer health online information. The one above it also looks at work safety and occupational health and safety. Would you like to expand on that and touch on that occupational health issue, because that is something I am particularly interested in.

Mr Arnold : The foundation has taken an interest in this over the last few years. If any of you are in Melbourne on Saturday the 14th, we have an up and coming fundraising ball where we will be issuing healthy skin awards again this year. The aim is to try and get out there to organisations, whether they be organisations who have won awards in the past—such as the Country Women's Association, Parks Victoria, the Victorian Trades Hall Council, the Meatworkers Union and the Macquarie Bank, for having skin checks for their staff, just like King & Wood Mallesons—or organisations who have not.

We believe there is a need to actually get the message out to industry broadly and also to the union bodies, such as the ACTU. The Trades Hall Council, certainly if we start on the workers' side, has done an excellent job in their occupational health and safety officers' online resource. They have a whole segment there on skin health. We were talking earlier with the previous speakers about outdoor workers. There is a range of information available there.

We believe there is a genuine role for peak bodies like the ACTU and trades hall councils in various states to be getting information out to their members around, 'This is about good skin health. If you are an outdoor worker, you need to be aware of this, that and the other.' Equally, that is for them to be aware of what the rules and regulations are around outdoor workers, such as that they should be wearing hats. I was very interested to hear the previous speaker talking about the big firm, the medium firm and the small firm. There is clearly a lot of work to do to get out there with the information.

The other side of it is, as I mentioned before, that we are working with the Victorian government's cancer prevention framework. The Minister for Health at the moment is even looking at getting information out to his colleagues, who have the industry portfolio and the work safety portfolio, to be encouraging them to see what can be done in their portfolios to get the information out. I think there is a role to be played by government, by industry associations, by ACTU and by others to work with organisations like ourselves. We have got ample information that can be put there. We just think there is such an opportunity.

Ms HALL: And employer bodies?

Mr Arnold : Yes.

Prof. Baker : There is one thing that Chris might have mentioned, quite apart from the fact that tickets to the ball are still for sale.

Ms HALL: Hear that!

Prof. Baker : We welcome all Australians. The foundation has a division within its research arm called the Occupational Dermatology Research and Education Centre—ODREC. It is not something out of Blackadder. It is actually quite a serious research unit, headed up by associate professor Dr Rosemary Nixon. The work that has been published out of that area has been recognised worldwide. We are taking quite a strong leadership on the issue of occupational risk.

Mr WYATT: Just on that, why are you not taking the same level of interest and push with schools—which in a sense are a workplace for secondary school kids—and fishing, recreation and sporting?

Mr Arnold : Can I comment on that, with the first one around schools.

Mr WYATT: I am talking about secondary schools.

Mr Arnold : Yes. We have actually been involved with a woman in New South Wales who has developed a program to roll out to schools. Mela-What is the name of the program. As in melanoma, it is called Mela-What. She has actually, with the University of New England, advanced that particular program and is piloting that at the moment as a secondary school program. We have been involved in the earlier stages of that and she actually supports our March Against Melanoma each year. That is one area.

Secondly, with the committee I mentioned before in Victoria, there is a range of initiatives happening out of that at the moment around shade in schools and playgrounds. It has just not been our primary focus at this stage as a foundation. There are multiple things. We have a budget of $6 million a year and not $60 million a year. Probably that question would be a good one to ask the Cancer Council. I know they have been very actively involved at the primary level.

The second part of your question was around sport and recreation. For those of you who are AFL supporters, we are engaged and have set up a relationship with the Collingwood Football Club. I will duck under the table now for those of you who are now Collingwood supporters! They are genuinely interested in involving the foundation in getting the skin and skin health message out to the players and also to their broader group. They have over 250,000 people on their Facebook account. They have their own little TV channel. They are talking to us about next year getting us involved in their player and supporter days. They will have a whole bunch of people come there and get us to go there and give a skin health message and so forth.

I think we have tried in the past to approach Cricket Australia, only to be told, 'We have three partner charities a year that we work with for a three-year period. Come back in three years time.' Tennis Australia, as you might be aware, were already linked up with Cancer Council Victoria. They were already providing the skin health message out there. We have also tried through the AFL Players Association and did not get anywhere there.

Ms HALL: What about NRL? Looking at that, that is where it is greatest.

Mr Arnold : We are identifying groups and progressively—particularly since Peter has joined us in the last six months—running them down and having discussions with quite a range of different sporting bodies. That is because we agree with you. We think it is an absolutely sensible thing to do.

Ms RISHWORTH: I have one question, just to wrap it up, looking at recommendations 1 and 8 of yours. It does suggest a more coordinated approach on a federal level. Certainly, a recommendation this morning from VicHealth was that a coordinated strategy—more than just a media strategy, which is your recommendation 1—would really help the states and territories determine and get on the same page. Would you even go further than recommendations 1 and 8 to support that?

Mr Arnold : We are really just saying that we believe it is a very sensible thing to have guidelines for Australia. Australia, as a whole, has the worst instance of skin cancer and melanoma in the world. We believe in having a coordinating resource like that available to the federal government, drawing on the expertise around Australia and coming up with single guidelines. We have just in fact done this in the area of area of psoriasis recently, where we go together Australia's experts and came out with statements on psoriasis. We think it would be very useful—again, multidisciplinary—to be able to come out with some definitive statements and standards that can be used and then translated into appropriate media.

CHAIR: Gentlemen, thank you for coming along today. We appreciate the time you have taken. If you have been asked to provide additional information, could you please forward it to the secretariat by 20 June. If the committee has any further questions, they will send these to you in writing through the secretariat. If you feel that you have got other further evidence that would assist the inquiry and the committee, please feel free to forward it on. We look forward to seeing the photos of your ball on your website. The committee will now suspend for 15 minutes until 10.50.

Proceedings suspended from 10 : 35 to 10 : 52