Opening Address Pandemic Influenza Primary Care Forum, AMA President, Dr Mukesh Haikerwal

Welcome to this important Forum.

I am pleased to open this meeting - the meeting we had to have.

I note the short notice and difficulties in making the arrangement, but that is the nature of the beast.

We'll have to work and act, often at short notice.

So congratulations to the Department for pulling this together.

It's not the end, but the beginning of a very important process.

We must formally and fully engage the capabilities and capacity of General Practice and others responsible for community health care.

We have seen the various scenarios for a potential pandemic, be it an influenza, and whether that be Avian, in varied graphic and alarmist detail.

The public concern is fuelled by reminiscences of the Spanish Influenza pandemic of 1918, the concerns of bio-terror from weaponised Anthrax or Smallpox, the recent SARS outbreak and the roll call of dead birds and infected humans from across the globe.

The UN proclaimed that between five million and 40 million people would die worldwide.

The local scenario of the deaths of thousands of people requiring Army bulldozers to dig trenches to bury the dead was unfurled.

The outrage about the unavailability of anti-virals reached a crescendo.

It was vital we stopped this escalation of angst, took stock and pleaded for calm review and clear guidance.

The Brisbane meeting of APEC's "Gurus of 'flu" and their more sage pronouncements broke the cycle of hysteria and mis-information which diverted the real messages and the real attempts that were being made in preparation for a flu pandemic.

The Federal Department of Health and Ageing's own Pandemic Blueprint, The Australian Management Plan for Pandemic Influenza, is an excellent document.

There are also similar plans developed by the States and Territories, which are set to work in conjunction with the Federal plan.

There is an accepted need however, to close the final loop and let those of us currently providing medical services in the community, who are expected to be involved and expect to be involved, know when and how they will be engaged.

The AMA has been calling for more involvement of primary care level health service providers in the development of the Pandemic Plan since the Federal Government released the Australia Action Plan for Pandemic Influenza in October 2003 and formed the National Influenza Pandemic Action Committee (NIPAC).

The plan must effectively use the capacity of General Practices and clarify their expected modus operandi. It must come to that conclusion only after proper consultation.

This plan was a "high level" over-arching plan. It was revised in 2005 but is not directly relevant to General Practice.

Action Plans with Action Committees have been established.

Most are still high level and differ significantly between Jurisdictions.

National level working groups are hard at work on clinical guidelines, border protection, immunisation, the safest, most effective use of antiviral drugs, laboratory diagnoses, infection control and so on. They are producing good work.

The information to and discussions with GPs and other staff at the primary care level is still extremely patchy and most of our members are still very unclear about what their roles and responsibilities will be.

Hence I am pleased about this meeting. It will hopefully allow networking and the sharing of lessons and ideas that will help us all work together.

But to repeat, this is only the beginning of primary care engagement.

We need a "communication strategy" so that GPs and other primary care staff know what is going on, what plans are being made, and so on.

But effective primary care delivery will need more than this.

The providers of primary care need to be better engaged in developing national, State and in particular local Action Plans.

General Practice will be the front line in any pandemic. People will go to where they know for advice and treatment.

GPs and their staff are the ones who are best placed to suggest how coping with the numbers and the contagious nature of the illness might be achieved once the technical guys have defined what needs to be achieved.

For instance once vaccine is available how and where should it be administered?

How and when is the National Medicines Stockpile to be used in the community?

Someone sitting in an office in Canberra or Melbourne, however highly qualified, is not going to know which school hall or community building would be best for the purpose. Nor who should supervise and who should actually administer vaccines?

The ideal solutions will be different in different places.

Once the level of infection in the population reaches a certain level, general practices are likely to become centres for passing the infection on.

Should they then be closed?

Should they re-arrange their services in conjunction with other local colleagues?

Clubbing together would allow for consultation time and factor in some rest!

A stream for influenza and one for other ailments?

We need the discussion.

We will need local solutions to how patients get to see a doctor.

Maybe they sit in their cars in the car park and come in one at a time.

The fast food-style drive-thru surgery has some attraction too!

Or maybe an open-air surgery is the answer.

Only a local will know the best location for these services.

Primary care itself is the best place to generate, if not answer some technical questions and many practical questions.

Our frontline carers must be part of the solution.

They must be confident that solutions will work.

Different health service communities must discuss and develop local action plans.

Local action plans obviously need to be informed by National and State and Territory plans and by the technical information already developed.

The facts about medications and immunisations for instance do not change from region to region.

The nuts and bolts of what will need to be done in the event of an outbreak vary in urban, rural and remote areas and depend on the availability of health facilities, doctors and other medical staff.

Whilst we must be careful not to spread panic in the community, we need to be honest with each other.

We need to be honest with the public.

I don't know if there'll be a pandemic flu, but it is better to be prepared.

Members still ask:

What they will need to do and be expected to do?

How will they be communicated with, how they will give information?

How will they run their normal practice?

Industrial issues around financing of equipment, waste disposal, man hours and around indemnity will need to be addressed.

As questions like these are answered, will we be "prepared enough".

We must be careful with language.

There is serious misunderstanding in the general public that Avian flu is a pandemic flu.

It is not.

It can only become a pandemic after significant mutation of the virus.

The current fight in Asia is to limit the circumstances that will increase the likelihood of such a mutation.

We must continue to show a willingness to help the front line countries in this fight.

We must be vigilant in our watch for the arrival of an Avian flu in birds in Australia and be prepared to stamp it out.

During the mutation, the virus may become less.

If we are faced with a virus that mutates into one that is highly infectious to humans and pandemic affected 25 per cent of the Australian population, we could expect (13,000-44,000) deaths, (57,900-148,000) hospitalisations and (2,600,000-7,500,000).

It is likely that we will have some warning from overseas about an approaching pandemic and the Federal Government will put in place measures to reduce the likelihood of it coming to Australia.

We will need a good surveillance system at the primary care level.

The AMA welcomes the announcement of the extra funding of $184.8 million for national health emergencies announced on Sunday by the Minister for Health & Ageing - in particular the $6.5 million that has been allocated to expand the influenza surveillance networks.

The present sentinel system needs to be expanded to enable early reporting on other potential public health emergencies related to disease outbreaks.

The Australian Sentinel Research Network or ASPREN run by the Royal Australian College of General Practitioners (RACGP) in association with the University of Adelaide, provides information on influenza-like illness in the community and could provide early identification of influenza outbreaks.

Whilst acknowledging the commitment to this, we question whether the one off $219,000 from this pot of money is adequate, particularly in light of the need to greatly expand the number of GPs involved across the country.

This funding level reflects a limited understanding of the significant role GPs play in the early identification of potential health emergencies.

It is important that the level of GP involvement in the sentinel system be increased.

Early warning systems, particularly at a local level, offer the real opportunity, in the case of public health emergencies related to infectious disease, to introduce containment measures.

Present systems of reporting, particularly through State Health Departments and then to Federal systems are not timely enough to deliver information in a manner that allows a speedy response so necessary for containment and are inadequate in the context of real public health emergencies.

The funding doesn't appear to cover the development of a comprehensive communication system that permits doctors, hospitals and other health facilities to get access to the right information at the right time from a single reliable source.

The AMA believes this is essential to an effective public health emergency strategy.

Such a communication system should also provide the capacity to address localised events and be able to communicate to specific doctors or facilities in a particular area.

It should also provide a number of communications methods including at least one real time method.

The AMA has submitted a proposal to Government that we believe can deliver such a system - we will make the details of the proposal public in the near future.

The AMA also welcomes the allocation of some of this funding, $34.4 million in fact, to the establishment of an Office of Health Protection.

While not listed in its responsibilities we would hope that this office will improve the level of consultation with primary care, particularly GPs.

Also the access to equipment and training would be seen as an important role to build capabilities.

Australia is said to have more advanced plans than other countries but more is needed.

As I said, our members DO NOT FEEL they know what is going on, they do not feel that they know what their role will be, they do not trust that it will be OK on the day, the weeks and months when the health system will be overwhelmed with critically ill people.

As the SARS outbreak in Canada demonstrated the failure of Government to identify GPs as central in such an emergency meant the workforce had to develop their own devices, particularly around communication.

We must learn from their experience.

Further, doctors in Australia are already asking themselves what they would do in the event of a public health emergency such as a pandemic flu outbreak.

Their main concerns centre around containment and maintaining care to both infected and non infected patients. How they would protect their patients in their rooms from infection.

How do they ensure they care for patients who are not infected?

Would they close their surgeries and undertake home visits?

Is this feasible given the likely demand on their services?

How will they use their practice nurses and what sort of implications will this have for how they organise their businesses and the care they deliver?

Indeed how would they protect themselves and their own families from both direct infection and from the aversion that accompanies the stigma of being potential sources of infection.

The Canadian experience demonstrated that looking after and preventing the existing workforce becoming infected is critical to maintaining an effective system to manage the infection.

The Canadians found that as doctors and nurses became infected or were quarantined the workforce increasingly diminished and the systems simply could not cope.

Doctors also want clear advice on infection control protocols surrounding specific disease outbreaks.

These need to be provided by one single source and be reliable and consistently updated as new information flows.

The same applies to clinical updates.

The Canadians again found themselves in a situation where doctors had to develop their own communication system to ensure clinical treatment updates from doctors at the coal face were transmitted quickly to their colleagues.

A strong, comprehensive and systemic strategy for consultation with GPs must be a feature of planning around national health emergencies, including pandemic influenza.

GPs and other specialists need to be confident they understand their role.

They need adequate information on what decisions they need to make about such things as providing ongoing care for ALL their patients, who do they listen to and what clinical and infection control equipment is needed.

Much of this information is likely to vary depending on what sort of health emergency it might be and in that context confidence can be delivered by Government ensuring that it covers all the bases, in consultation with the profession, and can ensure access to accurate and reliable information swiftly to all doctors.

The Pandemic Plan document is not accessible to GPs.

It is too long and too broad and does not answer the questions they are asking.

We need a specific document on primary care that links to the broader plan, particularly to the different phases of a potential pandemic.

Doctors need to know what they must do now, what they must do or decide at what stages of a pandemic threat and outbreak, what their role is in other parts of the health sector strategy eg fever clinics, hospitals, how they protect themselves and their staff, particularly in the interests of maintaining an effective health workforce.

Additionally they must be heard on the issues around maintaining the viability of their businesses during a health emergency.

The profession, in consultation with Government, must undertake this work.

It is the AMA's view that this information must be provided through a separate and accessible planning and strategy document that is linked to the broader pandemic planning plan.

History of the Spanish flu tells us all did not go smoothly that time. There were conflicts between what different States and Territories did.

We must learn from this.

Yes there are differences because each area has different infrastructure but there also needs to be a degree of uniformity.

Whether or not we survive must not depend on which State or Territory we happen to live in.

So let us move on to the meat of today's meeting. Let us identify the key issues and areas of concern for Primary Care and let's plan how to ensure these are resolved.

It's going to be a tough situation to deal with.

Things will go wrong.

There will be casualties.

There is no choice but to persevere, to act.

We can't plan for everything: we may well miss things: but we'll need to roll with the punches.

Today is about supporting the GPs and other carers in the community with this important task.

We need to work together, inform each other and be informed and ensure we do the best we can.

Thank you again for oranising this and for asking me to speak today.