Open letter: Progress on height adjustable examination beds

I am issuing this open letter to provide information on progress made in relation to the availability of adjustable-height examination beds in general practices throughout Australia .

While there have been some welcome developments I remain concerned that many people with a disability do not have equitable access to the same quality of health care at general practices as other patients.

Background

In 2003 a community advocacy group, Access for All Alliance, undertook a survey of all general practices around Australia to identify which provided access to adjustable-height examination beds. The survey showed that of the 3553 response there were just over 14000 fixed examination beds and only 719 adjustable-height examination beds. As some general practices had more than one adjustable-height examination beds the 719 identified do not represent 719 surgeries with them. [ http://www.humanrights.gov.au/disability_rights/health/access.doc ]

The report from Access for All Alliance provided some personal accounts of situations arising because general practices did not have an adjustable-height examination beds:

• One woman had not had a Pap smear for 10 years because her doctor could not transfer her onto the fixed height examination bed.
• Another woman had not had a pap smear for 20 years in her doctor's surgery because she was unable to be transferred to the fixed height examination bed and she was forced to ask for home visits to have this undertaken. Although on a disability pension, her doctor's bills were therefore highly inflated because of the cost of home visits for all her medical problems.
• A young man in a wheelchair said he had visited the doctor in order to have a prostate examination. This was undertaken after he had been lowered onto the floor, because he could not be transferred up to the fixed height examination bed from his wheelchair.
• A woman in a wheelchair told of recently going to have a Pap smear at which time she too was transferred onto the floor of the doctor's surgery. She was spread-eagled, with her husband holding her legs apart for this procedure. Her comment to the author of the survey was "Oh so undignified".
• A woman wrote: "My doctor does not have a height adjustable examination table, he lifts me onto the table which is an indignity, even though he is such a respectful man. However I would not allow the other doctors in the practice to do this".

The lack of availability of adjustable-height examination beds clearly has serious consequences for patients with a disability seeking to access quality general practice care and for people who work in general practices. These include:

Getting a service

In many situations patients, particularly women with disability do not get a service at all because of the inaccessibility of fixed height examination beds . A number of studies into breast and cervical cancer screening among women with disability have found that one issue frequently cited as a source of difficulty in accessing medical services was the lack of adjustable-height examination beds .

[Nosek and Howland (1997), Breast and cervical cancer screening in women with physical disabilities , in Preventative Women's Health Care for Women with Disabilities - Background and Literature Review , NSW Cervical Screening Program (2004), available online at http://www.csp.nsw.gov.au/publications/index.html ; Keran Howe and Sue Salthouse (2004), "Lack of Data Means Lack of Action" - A clinical examination of access to health services for women with disabilities , Women with Disabilities Australia, available online at http://www.wwda.org.au/hreocsumm.htm ; Jenny Bridge-Wright (2004), Waiting to be Included - Breast and Cervical Cancer Screening, Where are the Women with Disabilities? , Women with Disabilities Australia, available online at http://www.wwda.org.au/screen1.htm ]

Quality general practice care

The evidence also suggests that when a general practitioner is unable to perform an appropriate examination because a patient cannot transfer onto the examination table, the patient receives poor quality and inequitable health care. The patient can be misdiagnosed, because the general practitioner is not able to obtain thorough enough information, or the patient can miss the benefit of early detection of a developing condition such as cancer.

By providing adjustable-height examination beds , general practitioners improve the quality of care they can give to all their patients as well as improving the quality of their patients' lives.

Occupational Health and Safety

OH&S issues are of growing concern in general practice facilities where injuries have occurred to employees who have been required to assist patients onto fixed height examination beds. Height adjustable examination beds would assist in reducing injury rates, insurance costs and the costs associated with employees being absent due to injury.

Legal liability and human rights

Under the Federal Disability Discrimination Act 1992 (DDA) and similar State and Territory laws health service providers such as general practices, hospitals and specialist services are required to provide their services in a non-discriminatory way.

If someone believed they were not getting a quality service equivalent to other patients, because of their disability, they could make a discrimination complaint. Failure to provide an adjustable-height examination bed could give rise to a complaint if it resulted in an inequitable or lesser quality service. The Commission has dealt with complaints on this issue.

In addition to existing legal responsibilities Australia has recently become a signatory to the UN Convention on the rights of persons with disability which in Article 25 - Health says:

States Parties recognize that persons with disabilities have the right to the enjoyment of the highest attainable standard of health without discrimination on the basis of disability. States Parties shall take all appropriate measures to ensure access for persons with disabilities to health services that are gender-sensitive, including health-related rehabilitation. In particular, States Parties shall:

• Provide persons with disabilities with the same range, quality and standard of free or affordable health care and programmes as provided to other persons, including in the area of sexual and reproductive health and population-based public health programmes;

Universal Access

The provision of adjustable-height examination beds is not just an issue for people with disability. It will also significantly improve access and quality of care for all patients including older Australians, pregnant women, people whose illness results in restricted movement or capacity and obese Australians, as well as people with disabilities.

In keeping with the principles of universal access and design, adjustable-height examination beds can be used by the whole community and remain appropriate to its changing needs and circumstances.

Advocating for change

In 2004 Access for All Alliance presented their research at a national Forum on Health Access hosted by the Commission. The Forum was called to look at a range of health access issues following a call from Women With Disabilities Australia for the Commission to look into the lack of access to breast and cervical cancer screening services for women with disabilities.

Following the Forum representatives from the disability sector, and in particular People with Disability Australia (PwDA) and Women with Disabilities Australia (WwDA), resolved to work with the Royal Australian College of General Practitioners (RACGP) to find ways to improve the situation and ensure equitable access to quality care.

While the existing complaints mechanism under the DDA was, and remains, available to individuals the advocacy organisations decided to pursue a strategy of negotiation.

While it was recognised that this problem was not unique to general practices-it is equally relevant to private and public hospitals, day surgery centres, community health centres and allied health care facilities such as physiotherapists and massage therapists-it was felt that this area of health care was the most critical to try and address.

Both the Commission and the disability sector advocated for a change to the RACGP's Standards for General Practices to include a mandatory requirement that adjustable-height examination beds be available in every general practice.

The Standards for General Practices set out a number of criterions for general practices to comply with in order to be accredited. While general practices are not required to be accredited under the RACGP Standards in order to operate, accreditation gives a number of benefits including access to funds from the Practice Improvement Program (PIP) which is provided by Federal Government for initiatives aimed at improving practice services.

In 2005 the Commission and the disability sector proposed that PIP funds could be used to purchase adjustable-height examination beds and supported the idea of approaching the Minister for Health and the Department of Health to consider supplementing PIP funds to specifically subsidise general practices purchasing beds.

The outcome - so far

In meetings and correspondence in 2006 and 2007 the Minister for Health has made it clear he supports the availability of adjustable-height examination beds in all general practices. He has also requested the Department continue to work with the RACGP in order to ensure that adjustable-height examination beds become an integral part of the infrastructure of general practice.

The Department has pointed out that is provides significant funding to general practices accredited under the PIP and that there is no restriction on how this funding is applied and that general practices may use it to purchase equipment such as adjustable-height examination beds.

However, the Minister has made it clear he is not in a position to provide direct financial support to general practices in relation to the purchase of adjustable-height examination beds, as to do so would set a precedent that could apply to other forms of equipment that are deemed to be essential but are not, or are only inadequately covered by the RACGP Standards.

The RACGP has stated that while it supported the availability of adjustable-height examination beds in general practices it would not at this stage make their availability a condition of accreditation under their Standards.

In a letter to the Commission in March 2007 the President of the RACGP stated:

The RACGP has been careful to write Standards that are feasible to the profession. To take a different approach might have significant medico-legal implications, and undermine the broad acceptance of the process of meeting standards. At present the RACGP has concluded that feasibility of introducing height-adjustable beds precludes the introduction of a mandatory requirement for height adjustable beds in general practice. To depart from this position may set a precedent that proves problematic in the long term.

One of the reasons for this position appears to be that making adjustable-height examination beds a requirement for accreditation might disproportionately affect small general practices and in particular those that bulk bill and might result in general practices withdrawing from the Standards accreditation process.

They have, however, taken action to encourage general practices to provide adjustable-height examination beds including:

1. Updating its Standards for General Practices so that from 1 July 2007 they include an additional indicator to Criterion 5.13 Physical Access in relation to the availability of adjustable-height examination beds [ http://www.racgp.org.au/standards/513 ]

The RACGP Standards for General Practices include two levels of Criterion.

• Flagged items are mandatory for those General Practices wishing to achieve accreditation under the standards
• Unflagged items which indicate to General Practices issues that are best practice and encouraged but which are not mandatory for accreditation.

The additional indicator is an unflagged item which means that while RACGP encourage their members to comply with the Criterion it is not mandatory.

The Criterion now includes a new Addendum:

Criterion 5.1.3 Physical access The RACGP has been involved in an ongoing discussion with the disability sector and the Human Rights and Equal Opportunity Commission (HREOC) with respect to improving access to high quality general practice for people with a disability. HREOC has expressed concern that general practices may not be complying with the Disability Discrimination Act if they cannot provide effective access to height-adjustable beds for people with a disability, when required. People with disability are concerned that the issue be addressed in general practice, where most of their care occurs (despite being aware that the problem also arises in consultant specialists' rooms and other health services). The disability sector has had experts review the height adjustable beds available on the market, to ensure they meet the needs of people with disabilities. Simple, functional specifications for appropriate beds are available on the RACGP website at: http://www.racgp.org.au/standards/513 The RACGP continues to endeavour to ensure that affordable height-adjustable beds are available in the market. D. Our practice has a height-adjustable bed

1. Providing guidance to general practices about specifications for adjustable-height examination beds based on information collected by the disability sector:

Height Adjustable Examination Beds Minimum Requirements Preferred minimum range of height adjustment: 45-95cm Preferred minimum weight capacity: 175kgs Preferred minimum width of table: 71cm Preferred minimum length: 193cms Number of Sections: Two sections, where the head section can be raised Specific Purpose Features: - A side rail that can be moved up and down - Stirrups for gynaecological examinations Disability advocates indicate that these minimum requirements can be found in height adjustable examination beds currently on the market. The RACGP is currently negotiating with suppliers to provide the most cost effective options. This will be offered through GP Direct, from 1 July 2007 at the following site: www.gpdirect.net.au

 

1. Identifying potential suppliers with suitable adjustable-height examination beds to negotiate a preferred provider arrangement which will assist in reducing the costs involved for general practices. Work is almost complete on this initiative and a significant savings on the purchase of beds is expected.
2. Committing to surveying practitioners regarding the availability of adjustable-height examination beds and reviewing whether or not at some point they should become flagged and therefore mandatory.

The RACGP has also invited the Commission and the disability sector to prepare information and personal stories aimed at educating general practices about the legal issues and benefits of having adjustable-height examination beds.

While I welcome the actions the RACGP has taken and look forward to continuing to work with them to ensure equitable access to health care services I will continue to advocate for adjustable-height examination beds to be mandatory under the Standards for General Practices.

I am hopeful that the actions already taken by RACGP and the education and information strategies being put in place will result in a significant improvement in the availability of adjustable-height examination beds and support progress towards their inclusion as a mandatory item in the next review of the Standards.

In the meantime I will continue to advocate with the Department of Health that they do whatever they can to assist in promoting the availability of adjustable-height examination beds amongst RACGP members and other health care services that do not have access to PIP funds.

Finally I will seek clarification from RACGP on how they intend to monitor the availability of adjustable-height examination beds and what timetable and criteria they intend to establish for reviewing the current unflagged status in the Standards.