Volume 212 Issue 9

Information on COVID‐19 and its impact is being updated constantly and Australia must continue to be prepared at all levels of the health care system An outbreak of a novel coronavirus, formally named severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) and causing coronavirus disease 2019 (COVID‐19), emerged in the city of Wuhan in Hubei province in central China in December 2019. The first cases were noted as a cluster of patients with pneumonia who were all linked to a live animal market, and testing found the presence of a previously unknown coronavirus. Coronaviruses are a group of viruses that affect both animals and humans, and several (OC43, 229E, HKU1 and NL63) are a cause of the common cold.1,2 However, two coronaviruses previously caused significant outbreaks associated with more severe disease: the SARS coronavirus in 2002–2003 and the Middle East respiratory syndrome coronavirus that emerged in 2012.1,2 In contrast to previous outbreaks, the rapid sharing of viral sequences enabled laboratories worldwide to develop diagnostic tests within weeks of discovery of the pathogen.3 An Australian laboratory subsequently isolated the virus from a clinical sample (the first to do so outside of China), and rapidly shared this virus with relevant global agencies, further aiding diagnostic, therapeutic and vaccine development efforts. Information on the new virus and its impact is being updated constantly. While ascertainment of the milder end of the disease spectrum varies between countries,4 the age‐specific severity profile appears to be relatively consistent.5 Age is clearly an important risk factor — there have been few severe cases reported in children, and a high case fatality risk in the elderly. However, it is not clear whether comorbidities reflect the age group affected or whether they are risk factors for severe disease.6,7 Early studies using data before the institution of public health interventions in China suggest that SARS‐CoV‐2 is as transmissible as SARS coronavirus and probably more transmissible than influenza viruses.8,9 Emerging data suggest that viral load is highest around the onset of illness in milder cases, and transmission may occur during this pre‐symptomatic period.10,11,12 Careful analysis of early data suggests that the mean incubation period is 6 days, with a range of up to 14 days.13 There have been a considerable number of large clusters associated with large events, including religious communities, weddings, business meetings, closed communities, dormitories and cruise ships.14,15,16,17 The importance of infection control is also reinforced by a report that 41% of cases in Wuhan were acquired nosocomially (including 40 health care workers and 17 patients).6 Since the World Health Organization was first notified of this new pathogen, more than 2 million cases and over 130 000 deaths have been reported globally. On 16 April 2020, there were 6462 confirmed cases of COVID‐19 in Australia, including 63 deaths. After early outbreaks in Asia, the hardest hit countries currently are the United States and in Europe. There is great concern about low and middle income countries with limited diagnostic and public health capacity. The public health, political and societal ramifications have been considerable, with disruptive interventions that would have been unthinkable even a few months ago. Ultimately, a vaccine will be required; at the time of writing, 60 vaccine candidates have been developed, including three entering human trials (https://vac-lshtm.shinyapps.io/ncov_vaccine_landscape/). For clinicians, the main considerations are the clinical management of patients with suspected COVID‐19 but also systems to facilitate the identification of potential cases and to permit safe assessment and referral as appropriate. The experience with SARS and Middle East respiratory syndrome also reinforces the need for health services (both internationally and within Australia) to promptly identify patients with suspected infection and implement effective infection control measures, including adequate protection of health care workers. Based on clinical features, it can be difficult to distinguish patients with COVID‐19 from those with other respiratory viral infections, including influenza. Although the original case series described fever in almost all patients,7 further experience has noted cases with only respiratory symptoms, and even a small proportion with gastrointestinal symptoms.6 This has resulted in constant changes to case definitions, initially limited to febrile respiratory infections in travellers, but now including the full spectrum of illness in patients with broader epidemiological risk factors. Clinicians should refer to current information to guide testing and management (Box 1). Nucleic acid assays for SARS‐CoV‐2 are available at all Australian reference laboratories and commercial tests are now available in diagnostic laboratories. Compared with other countries, Australia has now performed a proportionately large amount of testing per capita.18 However, the sheer scale of testing has placed extraordinary pressure on supply chains for essential components required for laboratory testing, both in Australia and globally. Current World Health Organization advice is to test patients who meet the case definition for COVID‐19, regardless of whether another respiratory virus is detected, as co‐infections may occur.19 In recent weeks, surveillance for COVID‐19 has expanded to include a much broader range of risk factors to ensure capture of community transmissions. The role of serological assays (particularly point‐of‐care testing) in the overall public health response to COVID‐19 has yet to be defined, although peak bodies such as the Royal College of Pathologists note that there is no role for point‐of‐care assays in the diagnosis of acute COVID‐19.20 Lessons of the past are instructive for Australia, particularly the experience in Canada with its similar federated government and comparable health care system. In 2003, an outbreak of SARS coronavirus in Toronto infected 438 people and caused 44 deaths, including many health care workers. Following this public health disaster, two important reviews were conducted: the National Advisory Committee on SARS and Public Health,21 and Ontario's SARS Commission.22 The former reinforced the need for a strong and adequately funded nationally coordinated public health and laboratory system and led to the establishment of the Public Health Agency of Canada. The SARS Commission made detailed recommendations, including endorsing the “importance of the precautionary principle that reasonable efforts to reduce risk need not await scientific proof [which] was demonstrated over and over during SARS”.22 It made recommendations regarding clear governance, preparing for the need for unexpected interventions (including the closure of three hospitals to control the outbreak), effective distribution of outbreak alerts and directives, the need for effective crisis communication, and the value of robust and timely surveillance. With the involvement of health care workers as cases, the Commission highlighted the need to listen to frontline workers and unions and ensure a robust safety culture and effective infection control. We have many more information (and misinformation) sharing tools than were available in 2003. It has been breathtaking to watch the scientific process unfold in almost real time. Rapid genomic sequencing and online databases are being used to generate and analyse primary data. Preprint servers and rapid review in traditional journals are quickly publishing research findings. Research centres and platforms are responding to rapidly collect data and evaluate interventions. Social media and traditional media platforms are disseminating public health messages and findings. However, the fundamental structure of our public health care system remains unchanged, with the same channels of formal communication and direction through jurisdictions and national networks. A future review should consider whether surveillance and response for all infectious disease threats could be better coordinated by a centralised national agency. There are still many major unresolved clinical and public health issues (Box 2). Clear communication to the public and to clinicians has been difficult, particularly with constantly changing epidemiology and evidence. Australia was not significantly challenged by the two previous zoonotic coronavirus outbreaks, but this global crisis has now significantly disrupted the lives of all Australians. With thousands of cases reported in Australia, public health authorities, governments at all levels, researchers and clinicians, laboratories and the community need to continue to work together in a timely and transparent manner to ensure an effective response. Box 1 – Useful sources of official information* Australian information Australian Government Department of Health: https://www.health.gov.au/health-topics/novel-coronavirus Smart Traveller: https://www.smartraveller.gov.au/ Jurisdictional health department sites: New South Wales: https://www.health.nsw.gov.au/Infectious/diseases/Pages/coronavirus.aspx; Victoria: https://www.dhhs.vic.gov.au/coronavirus; Australian Capital Territory: https://www.health.act.gov.au/health-professionals/chief-health-officer-alerts; Tasmania: https://www.coronavirus.tas.gov.au/; South Australia: https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/clinical+topics/infectious+disease+control/novel+coronavirus+%282019-ncov%29+infection+for+health+professionals/novel+coronavirus+%282019-ncov%29+infection+information+for+health+professionals; Western Australia: https://ww2.health.wa.gov.au/Articles/A_E/Coronavirus; Northern Territory: https://coronavirus.nt.gov.au/; Queensland: https://www.qld.gov.au/health/conditions/health-alerts/coronavirus-covid-19 International situation reports and resources World Health Organization: https://www.who.int/csr/don/12-january-2020-novel-coronavirus-china/en/ United States Centers for Disease Control and Prevention: https://www.cdc.gov/coronavirus/2019-ncov/index.html European Centre for Disease Prevention and Control: https://www.ecdc.europa.eu/en/coronavirus * Websites viewed April 2020. Box 2 – Major unresolved clinical and public health issues Clinical Optimal samples for diagnostic testing (upper versus lower respiratory tract samples) Utility of existing and investigational antiviral agents and other treatments Host risk factors associated with poor clinical outcomes Public health and control The long term public health strategy for control to minimise morbidity and mortality, but taking into account broader impacts of health, the economy and society The optimal mix of case finding and isolation, contact tracing and quarantine, social distancing and personal hygiene Optimal, yet pragmatic, infection control measures to prevent infections in health care facilities and residential aged care facilities

Allen C Cheng · Deborah A Williamson

An objective measure could support GPs’ clinical judgement and aid discussions about the need for on‐road testing or driving cessation Assessing fitness to drive in older people is an increasingly important but challenging role for general practice. General practitioners are often the first port of call for concerned family or friends, and many Australian states and territories require older drivers to undergo regular assessment of their health and fitness to drive. Some GPs are uncomfortable in this role, citing concern to maintain relationships with older patients, concern about the impact of driving cessation, lack of familiarity with legal responsibilities and local resources, lack of training and clear guidance, lack of an objective measure, and poor access to on‐road driving assessments.1,2,3,4 Some GPs report sleepless nights having assessed an older person as fit to drive for another year.1 While the answer might be simple — that is, to speak to the older person and their family — this is not always straightforward. An objective measure of driving fitness could help. The number of older drivers in Australia is increasing, as is the number of seriously or fatally injured very old drivers (≥ 85 years of age).5 Older people are more vulnerable in road traffic accidents and are more likely to die or suffer severe injury.5,6 While road deaths in Australia have decreased overall in the past ten years (19%), road deaths in older people (≥ 75 years of age) have increased (23%).7 Driving is a complex task requiring sensory input (vision, hearing), cognitive function (attention, comprehension, memory, decision making, reaction time), and motor function (power, coordination).8 Ageing is associated with decline in sensory, cognitive and motor function. Accidents can happen to anyone, but road traffic accidents involving older drivers often receive widespread media attention. Recent examples include Prince Philip's driving accident at the age of 97 years, and the 86‐year‐old driver on the Sunshine Coast who reversed over and killed a 6‐year‐old girl.9 However, the loss of a driver's licence can be a devastating blow to independence and wellbeing.10 While many older drivers are safe and cautious drivers aware of their limitations, some are not. GPs play a key role in monitoring driver safety. GPs have two main responsibilities: to assess and make a recommendation on a driver's health and fitness to drive when requested, and to report to the relevant licensing authority any impairment adversely affecting a driver's ability to drive safely when impairment is known. The duty to report is discretionary in most Australian states, but in South Australia and the Northern Territory it is mandatory. Doctors who report in good faith are protected from civil and criminal liability for breaching patient confidentiality, except in the NT where there is no express legal protection.8 The requirements for medical assessment in older drivers of private vehicles vary across Australian states and territories (Box).8 In Queensland, the Australian Capital Territory and New South Wales, drivers are required to undergo an annual medical assessment from the age of 75 years; in Western Australia, drivers are required to have an annual assessment from 80 years of age; while in SA, the NT, Victoria and Tasmania, there is no specific age‐based requirement. Some states require on‐road testing from the age of 85 years for some licence classes. Each state licensing authority has developed its own medical assessment form, with substantial variation in the information collected. SA has the longest assessment form, with 73 tick‐boxes listing medical conditions. SA and WA also collect information about recent involvement in road traffic accidents. Most states require drivers to submit the completed form to the licensing authority themselves, but some states give GPs the ability to complete and submit the form online, preventing drivers discarding unfavourable assessments and doctor‐shopping. The GP role in assessment is to ensure that the health of older drivers meets medical standards and does not unduly increase their crash risk. Austroads and the National Transport Commission have produced an extensive document to guide GPs in assessment.8 While the Austroads document has much useful information, some GPs say its utility in the time‐pressured context of general practice is limited, and that the document lacks clear guidance on referral thresholds and use of screening tests.1,2 The document recommends that GPs assess functional ability across three domains — sensory, cognitive and motor function — and that the key question GPs should consider is: “Is there a likelihood the person will be unable to control the vehicle and act or react appropriately to the driving environment in a safe, consistent and timely manner?”.8 The document provides detailed guidance on the medical standards for driver licensing purposes for many medical conditions; however, it is less clear regarding the increasingly common grey zone where an older person may be mildly impaired across several domains, with multiple interacting conditions including mild cognitive impairment and multiple medications. The document recommends: “Professional judgement must determine what is acceptable decline … and what is irreversible, hazardous deterioration in driving‐related skills that requires reporting to the licensing authority”.8 If GPs are uncertain or concerned, the document recommends that they refer older drivers to a medical specialist or general occupational therapist for assessment, or to a driver assessor occupational therapist for on‐road testing.8 On‐road testing “remains the most accurate way of determining fitness to drive”.11 However, on‐road testing is likely an imperfect predictor of future crash risk,12 especially in the context of fluctuating health conditions, and in Australia can be difficult to access, especially in rural and remote areas, and costly.1,2 In practice, GPs often use the relevant state or territory medical assessment form to guide their assessment, and make their recommendation based on clinical judgement sometimes informed by a single cognitive screening test.1 The in‐office screening tools that GPs report using most often in Australia include the Montreal Cognitive Assessment, the Mini‐Mental State Examination, the clock‐drawing test, and the Trails Making Test.1,2,4 However, despite their widespread use in clinical practice, single screening tests do not reliably predict driving risk.13,14,15 A toolkit comprising a composite battery of tests correlates better than any single test with the on‐road driving assessment.13,14,15,16 A toolkit validated for use in general practice is needed. Such a toolkit would not replace the occupational therapist on‐road assessment, but could support GP clinical judgement in differentiating older drivers in need of on‐road testing or driving cessation, and could be used as a communication tool to support a recommendation for further assessment or driving cessation while preserving relationships (“the test says …”). A toolkit used regularly, say annually, might demonstrate change over time, which could guide discussions about the need to plan for eventual driving cessation. Several toolkits have been developed and tested internationally, but their uptake in general practice has been limited, sometimes by the need for special equipment or input from family members.11,14,17 To be feasible in the Australian general practice context, any toolkit would need to be easy and quick to administer and require no expensive equipment or special training. Ideally, a toolkit would assess across all three functional domains and have face validity with older drivers, as some older drivers may, for example, consider memory tests irrelevant to their driving ability. A toolkit developed and tested by a Belgian group looks promising.18 This toolkit comprises visual acuity using the Snellen chart, the Functional Reach Test,19 and a road signs recognition test (a component of the Stroke Drivers Screening Assessment20). These tests assess across all three functional domains and are potentially readily accessible in general practice. When tested in Belgian drivers aged ≥ 70 years, the three tests together correctly classified two‐thirds of drivers compared with the on‐road driving assessment.18 Preliminary use of the toolkit in three Australian GP practices (JM, GS) suggests that the toolkit is acceptable to both patients and practitioners, and that the tests can be completed in a timely fashion. No toolkit is likely to be perfectly sensitive and specific — there will always be a need for GPs to use clinical judgement. Nevertheless, an objective measure could support GPs’ clinical judgement and aid discussions about the need for on‐road testing or driving cessation. Work remains to validate and test a toolkit for use in Australian general practice. Box – Regulatory requirements for medical assessment of older drivers of private vehicles, and practitioner reporting duties, by Australian state or territory8 State or territory Medical assessment Patient declares crashes Duty to report Australian Capital Territory Annually from 75 years of age No Discretionary Not liable if report in good faith New South Wales Annually from 75 years of age No Discretionary Not liable if report in good faith Northern Territory Only when condition notified No Mandatory No express indemnity Queensland Annually from 75 years of age No Discretionary Not liable if report in good faith South Australia No prescribed period or age for licence class C, otherwise annually from 70 years of age Traffic crashes in past 5 years Mandatory Not liable if report in good faith Tasmania No prescribed period or age, but may occur if a condition or concern is declared or reported No Discretionary Not liable if report in good faith Victoria No prescribed period or age, but may occur if a condition or concern is declared or reported No Discretionary Not liable if report in good faith Western Australia Annually from 80 years of age, unless a medical condition requires earlier assessment Traffic offences and crashes Discretionary Not liable if report in good faith

Katharine A Wallis · James Matthews · Geoffrey K Spurling

Opportunities to recognise and invest in general practice research need to be realised General practice research is essential to quality general practice, building an evidence base for over 27 000 general practitioners working within the specialty who provide medical care to the majority of Australians.1 Over eight in ten Australians consult with their GP at least once per year, and two million people are seen each week in general practice.2,3 General practice, a medical specialty, is the first point of access to the health system, providing longitudinal care for all. It is essential for the delivery of efficient, equitable and effective health care services.4 General practice is unique, complex and continuing to evolve. A GP must have a good working knowledge of 167 problems to cover 85% of the conditions that they see most frequently,5 and management of multimorbidity has become the norm. The number of general practices appears to be declining, practices are becoming larger, and the proportion of GPs who are practice owners is decreasing.6 General practice research is key to optimising health care in this evolving context, but needs to be supported by the profession, funders and our professional colleges. Current challenges General practice has traditionally been seen as an applied discipline, rather than one with an academic underpinning, and research has therefore been undervalued. The undervaluing of general practice research is reflected in current research funding and a paucity of opportunities during specialty training. The proportion of National Health and Medical Research Council funding to primary care research has been consistently low,7 and this has continued in the current Medical Research Future Fund budget, with only $5 million of $392.5 million for the 2019–20 financial year specifically allocated to primary care,8 despite primary care being noted as a medical research and innovation priority for 2018–2020.9 The Medical Research Future Fund 2019 investigator grant opportunity for early to mid career researchers included primary care research as one of its 11 research priority areas, but it will not be known if general practice research specifically has been supported until the results of that round are released. In the context of this undervaluing, GPs who have completed PhDs have expressed concerns about insecure academic career pathways,10 and the current ageing GP research workforce may not be replaced.11 Additional barriers to general practice research include lack of funding for Australia and New Zealand's academic primary care peak body (the Australasian Association for Academic Primary Care), general practice research networks, and payments to adequately compensate practices for the time and resources required to participate in research. Recent achievements Despite the challenges, general practice has a long tradition of rigorous, detailed and credible scientific research. This work covers a broad range of research questions, utilising a range of methodologies and frameworks (Box). However, general practice research outcomes are often less visible as hospital admissions avoided, diseases prevented, complications averted and health services redirected are key outcomes.4 The generalist nature of primary care means that research must deal with heterogeneous populations, multimorbidity and complex health service delivery. What would health care look like without general practice research? Primary care is the most efficient, equitable and effective place to deliver health care for most of the population,4 and is underpinned by a growing scientific knowledge base as research in and about general practice has evolved and grown over the past 50 years.12 Research in this setting is required as never before, with an ageing population, increasing rates of multimorbidity, and management continuing to move out of the hospital and into the community setting.13 There is no other academic specialty that will focus on generalist care in the community, and general practice is integral to research translation. Without general practice, the health outcomes of the population will be poorer and less equitable, and associated with increased health costs.4 Contextual knowledge of primary care is essential for credible and relevant general practice research. It is hard to imagine research into cardiology, for example, without the involvement of cardiologists. However, it is not uncommon for research in health services and primary care to not involve GPs, or to involve them at a late stage in development. Without GP involvement, research outcomes are unlikely to be fit for the general practice environment or appropriate for patients attending primary care. Academic GPs play important roles in both research and teaching, including training academic GP registrars and supervision of primary care researchers and students more broadly. They contribute to shaping the policy and practice environment through representing general practice on guideline development groups and engaging with international colleagues to develop and implement research methodologies suitable for the primary care environment. Without support of general practice research and training, this expertise would be lost. GPs and practice staff work with academic GPs and play a critical role in the development and implementation of interventions, recruitment and data collection and interpretation. Without compensation for their time (participation in research often results in loss of income) and without the infrastructure of practice‐based research networks, this practice knowledge cannot be harnessed. Data collected from general practice that is not interpreted through a generalist lens with an understanding of the context in which general practice operates can result in conclusions that do not reflect practice. A lack of focus on general practice research and academic opportunities will have a flow‐on effect to the recruitment of new GPs. To build interest in general practice more broadly, attention needs to be paid to medical students who often believe there is little intellectual challenge in the profession and a lack of academic opportunities.14 The national General Practice Student Network, a network for medical students interested in general practice supported by General Practice Registrars Australia, provides an opportunity for academic GPs and the Royal Australian College of General Practitioners (RACGP) to link with medical students to showcase opportunities for GP research, teaching and academic training. Towards the future Vocational training will be transitioned to the RACGP and the Australian College of Rural and Remote Medicine from the federal Department of Health in January 2022. This presents a real opportunity for shaping the future of general practice training by acknowledging the importance of research to the discipline, expanding current academic registrar programs and encompassing key Australian Medical Council accreditation recommendations, including that appropriate candidates can enter research training during specialist medical training with opportunities to undertake intercalated research degrees.15 This would provide a foundation for a supported path in GP academia. The RACGP Expert Committee – Research is currently developing a research strategy that will address these issues. Advanced Health Research Translation Centres and Centres for Innovation in Regional Health exist around Australia, and are partnerships of hospitals, research institutes and universities developed to accelerate translation of research into clinical care. As these structures currently stand, primary care is often lost among the multitude of hospital partners and clinicians and researchers who have little experience of, or interaction with, general practice. The Centres work together as the Australian Health Research Alliance, which currently does not include primary care as one of its system level initiatives. A focus on primary care would provide a more meaningful option for engaging with community general practice and primary care, working collaboratively with properly funded and sustainable practice‐based research networks that have led to successful innovations in other parts of the world. The GP academic community would welcome closer collaboration with both the Medical Research Future Fund and the Australian Health Research Alliance. The promise of big data has huge implications for general practice, with many heralding this as the beginning of a new era, but big data without appropriate expert interpretation is likely to lead to misunderstanding. General practice has a long history of working with data, starting with Charles Bridges‐Webb developing the first general practice survey in 1961, laying the groundwork for the Bettering the Evaluation and Care of Health (BEACH) program.2 Large general practice datasets are now held by NPS MedicineInsight, Primary Health Networks, and departments of general practice (for example, the UNSW electronic Practice Based Research Network and the Data for Decisions program at the University of Melbourne). The ability to track the patient journey between primary care and hospitals is being realised through linked datasets. The National Primary Health Care Data Asset is now under development, and it is critical that this includes oversight and input of GP clinician‐scientists to ensure that data are not misinterpreted. General practice is an academic specialty based on an international body of literature and decades of research. However, in Australia we still have a way to go to understand why primary care works in our context, how to best implement change, and how to teach best practice to new clinicians. Recognising and investing in the value of general practice research will require a systems approach that includes medical student training, vocational training, and support of research infrastructure and GP clinician‐scientists to enable research and research training in general practice and translation into practice and policy. This investment in general practice research and infrastructure should reflect the size of general practice in Australia, the population it serves, and the proportion of the associated Medicare spend. Box – Examples of general practice research informing clinical practice and health service design Research Key findings and implications for general practice General practice research involvement ASPirin in Reducing Event in the Elderly (ASPREE)12 Higher all‐cause mortality was found in healthy older adults in Australia aged over 70 years of age who received daily aspirin. This suggests that aspirin may not be of benefit for primary prevention of cardiovascular disease in this age group Mark Nelson (principal investigator) and Nigel Stocks were authors on this randomised controlled trial. Australian GP Associate Investigators in clinical practice recruited 87% of the 19 114 patient participants What treatments are effective for common colds in adults and children? Decongestants alone, or with antihistamines or analgesics, can be helpful for adults with nasal symptoms, but other commonly recommended treatments such as echinacea, vapour rub and heated, humidified air have no evidence of effect Systematic review led by Mieke van Driel13 Comparing non‐sterile to sterile gloves for minor surgery: a prospective randomised controlled non‐inferiority trial14 Non‐sterile gloves are not inferior to sterile gloves in regard to wound infection for minor skin excisions in general practice Trial led by Clare Heal, conducted in a single private general practice in Mackay, Queensland How to increase uptake of long acting reversible contraception (LARC) through general practice15 Online GP training in effectiveness‐based contraceptive counselling, together with GP access to rapid referral to a LARC insertion clinic increases LARC uptake by women Cluster randomised controlled trial in 57 general practices in Melbourne led by Danielle Mazza Bettering the Evaluation and Care of Health (BEACH)2 The BEACH dataset, consisting of almost 1.8 million GP–patient encounters recorded between 1998 and 2016, has been used to inform general practice research, education and policy Each year, about 1000 GPs recorded data about 100 consecutive patient encounters, contributing to the development of the BEACH dataset. Graeme Miller was the Medical Director of BEACH Clinical outcomes of an integrated primary–secondary model of care for individuals with complex type 2 diabetes: a non‐inferiority randomised controlled trial16 GPs with special interests working with a Beacon model of integrated care for diabetes achieved clinical outcomes that were not inferior to hospital‐based specialist clinics, with greater patient satisfaction Claire Jackson co‐led the development and evaluation of the Beacon model, which has now also been adapted and utilised in Western Australia Composite Abuse Scale17 The Composite Abuse Scale was developed as a research tool to classify women according to type and severity of abuse. It has been translated into eight languages and is considered the standard for assessing women's self‐reported experiences of abuse The Composite Abuse Scale was developed by Kelsey Hegarty and used in a cluster randomised controlled trial to identify women who screened positive to intimate partner violence and who may benefit from brief counselling from their GP

Jo‐Anne E Manski‐Nankervis · Elizabeth A Sturgiss · Siaw‐Teng Liaw · Geoffrey K Spurling · Danielle Mazza