Roles of health professionals are still unfortunately often stuck in the past. That is, before the shift of education of nurses and other health professionals into universities in the 1980s. So many are still not working to their full scope of practice.

There has been some expansion of roles in recent years – including pharmacists prescribing (under limited circumstances) and administering a wider range of vaccinations.

But the recently released paper from an independent Commonwealth review on health workers’ “scope of practice” identifies the myriad of barriers preventing Australians from fully benefiting from health professionals’ skills.

These include workforce design (who does what, where and how roles interact), legislation and regulation (which often differs according to jurisdiction), and how health workers are funded and paid.

There is no simple quick fix for this type of reform. But we now have a sensible pathway to improve access to care, using all health professionals appropriately.

A new vision for general practice

I recently had a COVID booster. To do this, I logged onto my general practice’s website, answered the question about what I wanted, booked an appointment with the practice nurse that afternoon, got jabbed, was bulk-billed, sat down for a while, and then went home. Nothing remarkable at all about that.

But that interaction required a host of facilitating factors. The Victorian government regulates whether nurses can provide vaccinations, and what additional training the nurse requires. The Commonwealth government has allowed the practice to be paid by Medicare for the nurse’s work. The venture capitalist practice owner has done the sums and decided allocating a room to a practice nurse is economically rational.

The future of primary care is one involving more use of the range of health professionals, in addition to GPs.

It would be good if my general practice also had a physiotherapist, who I could see if I had back pain without seeing the GP, but there is no Medicare rebate for this. This arrangement would need both health professionals to have access to my health record. There also needs to be trust and good communication between the two when the physio might think the GP needs to be alerted to any issues.

This vision is one of integrated primary care, with health professionals working in a team. The nurse should be able to do more than vaccination and checking vital signs. Do I really need to see the GP every time I need a prescription renewed for my regular medication? This is the nub of the “scope of practice” issue.

How about pharmacists?

An integrated future is not the only future on the table. Pharmacy owners especially have argued that pharmacists should be able to practise independently of GPs, prescribing a limited range of medications and dispensing them.

This will inevitably reduce continuity of care and potentially create risks if the GP is not aware of what other medications a patient is using.

But a greater role for pharmacists has benefits for patients. It is often easier and cheaper for the patient to see a pharmacist, especially as bulk billing rates fall, and this is one of the reasons why independent pharmacist prescribing is gaining traction.

Every five years or so the government negotiates an agreement with the Pharmacy Guild, the organisation of pharmacy owners, about how much pharmacies will be paid for dispensing medications and other services. These agreements are called “Community Pharmacy Agreements”. Paying pharmacists independent prescribing may be part of the next agreement, the details of which are currently being negotiated.

GPs don’t like competition from this new source, even though there will be plenty of work around for GPs into the foreseeable future. So their organisations highlight the risks of these changes, reopening centuries old turf wars dressed up as concerns about safety and risk.

Who pays for all this?

Funding is at the heart of disputes about scope of practice. As with many policy debates, there is merit on both sides.

Clearly the government must increase its support for comprehensive general practice. Existing funding of fee-for-service medical benefits payments must be redesigned and supplemented by payments that allow practices to engage a range of other health professionals to create health-care teams.

This should be the principal direction of primary care reform, and the final report of the scope of practice review should make that clear. It must focus on the overall goal of better primary care, rather than simply the aspirations of individual health professionals, and working to a professional’s full scope of practice in a team, not a professional silo.

In parallel, governments – state and federal – must ensure all health professionals are used to their best of their abilities. It is a waste to have highly educated professionals not using their skills fully. New funding arrangements should facilitate better access to care from all appropriately qualified health professionals.

In the case of prescribing, it is possible to reconcile the aspirations of pharmacists and the concerns of GPs. New arrangements could be that pharmacists can only renew medications if they have agreements with the GP and there is good communication between them. This may be easier in rural and suburban areas, where the pharmacists are better known to the GPs.

The second issues paper points to the complexity of achieving scope of practice reforms. However, it also sets out a sensible path to improve access to care using all health professionals appropriately.

Stephen Duckett, Honorary Enterprise Professor, School of Population and Global Health, and Department of General Practice and Primary Care, The University of Melbourne

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Today’s news coverage reports potentially unsafe levels of “forever chemicals” detected in drinking water supplies around Australia. These include human-made chemicals: perfluorooctane sulfonate (known as PFOS) and perflurooctanic acid (PFOA). They are classed under the broader category of per- and polyfluoroalkyl substances or PFAS chemicals.

The contaminants found in our drinking water are the same ones United States authorities warn can cause cancer over a long period of time, with reports warning there is “no safe level of exposure”.

In April, the US Environmental Protection Agency (USEPA) sent shock waves through the water industry around the world when it announced stricter advice on safe levels of PFOS/PFOA in drinking water. This reduced limits considered safe in supplies to zero and gave the water industry five years to meet legally enforceable limits of 4 parts per trillion.

So, should the same limits be enforced here in Australia? And how worried should we be that the drinking in many parts of Australia would fail the new US standards?

What are the health risks?

Medical knowledge about the human health effects of PFOS/PFOA is still emerging. An important factor is the bioaccumulation of these chemicals in different organs in the body over time.

Increased exposure of people to these chemicals has been associated with several adverse health effects. These include higher cholesterol, lower birth weights, modified immune responses, kidney and testicular cancer.

It has been very difficult to accurately track and measure effects of different levels of PFAS exposure on people. People may be exposed to PFAS chemicals in their everyday life through waterproofing of clothes, non-stick cookware coatings or through food and drinking water. PFAS can also be in pesticides, paints and cosmetics.

The International Agency for Research on Cancer (on behalf of the World Health Organization) regards PFOA as being carcinogenic to humans and PFOS as possibly carcinogenic to humans.

Our guidelines

Australian drinking water supplies are assessed against national water quality standards. These Australian Drinking Water Guidelines are continuously reviewed by industry and health experts that scan the international literature and update them accordingly.

All city and town water supplies across Australia are subject to a wide range of physical and chemical water tests. The results are compared to Australian water guidelines.

Some tests relate to human health considerations, such as levels of lead or bacteria. Others relate to “aesthetic” considerations, such as the appearance or taste of water. Most water authorities across Australia make water quality information and compliance with Australian guidelines freely available.

What about Australian PFOS and PFOA standards?

These chemicals can enter our drinking water system from many potential sources, such as via their use in fire-fighting foams or pesticides.

According to the Australian Drinking Water Guidelines, PFOS should not exceed 0.07 micrograms per litre in drinking water. And PFOA should not exceed 0.56 micrograms per litre. One microgram is equivalent to one part per billion.

The concentration of these chemicals in water is incredibly small. And much of the advice on their concentration is provided in different units. Sometimes in micrograms or nannograms. The USEPA uses parts per trillion.

In parts per trillion (ppt) the Australian Guidelines for PFOS is 70 ppt and PFOA is 560 ppt. The USEPA’s new maximum contaminant levels (enforceable levels) are 4 ppt for both PFOS and also PFOA. Previous news reports have pointed out Australian guidelines for these chemicals in drinking water are up to 140 times higher than the USEPA permits.

Yikes! That seems like a lot

Today’s news report cites PFOS and PFOA water tests done at many different water supplies across Australia. Some water samples did not detect either chemicals. But most did, with the highest PFOS concentration 15.1–15.6 parts per trillion from Glenunga, South Australia. The highest PFOA concentration was reported from a small water supply in western Sydney, where it was detected at 5.17–9.66 parts per trillion.

Australia and the US are not alone. This is an enormous global problem.

One of the obvious challenges for the Australian water industry is that current water treatment processes may not be effective at removing PFOS or PFOA. The Australian Drinking Water Guidelines provide this advice:

Standard water treatment technologies including coagulation followed by physical separation, aeration, chemical oxidation, UV irradiation, and disinfection have little or no effect on PFOS or PFOA concentrations.

Filtering with activated carbon and reverse osmosis may remove many PFAS chemicals. But no treatment systems appear to be completely effective at their removal.

Removing these contaminants might be particularly difficult for small regional water supplies already struggling to maintain their water infrastructure. The NSW Auditor General criticised the planning for, and funding of, town water infrastructure in regional NSW back in 2020.

Where to from here?

The Australian water industry likely has little choice but to follow the US lead and address PFOS/PFAS contamination in drinking water. Along with lower thresholds, the US committed US$1 billion to water infrastructure to improve detection and water treatment. They will also now require:

Public water systems must monitor for these PFAS and have three years to complete initial monitoring (by 2027) […]

As today’s report notes, it is very difficult to find any recent data on PFOS and PFOA in Australian drinking water supplies. Australian regulators should also require ongoing and widespread monitoring of our major city and regional water supplies for these “forever chemicals”.

The bottom line for drinking tap water is to keep watching this space. Buying bottled water might not be effective (2021 US research detected PFAS in 39 out of 100 bottled waters). The USEPA suggests people can reduce PFAS exposure with measures including avoiding fish from contaminated waters and considering home filtration systems.

Correction: this article previously listed the maximum Australian Drinking Water Guidelines PFOA level as 0.056 micrograms per litre. The figure has been updated to show the correct level of 0.56 micrograms per litre.

Ian A. Wright, Associate Professor in Environmental Science, Western Sydney University

This article is republished from The Conversation under a Creative Commons license. Read the original article.