Indigenous sexual health

BY AMA PRESIDENT DR MICHAEL GANNON

While successive governments have made significant efforts to address major chronic health problems experienced by Aboriginal and Torres Strait Islander people, sexual health issues are often left off the agenda. The rates of HIV and sexually transmitted infections (STIs) within Indigenous communities are increasing at alarming rates, and Aboriginal and Torres Strait Islander people are disproportionately affected by these conditions.

The serious consequences of untreated STIs are well documented, some of which are known have long-term effects on health. Syphilis, for example, is highly infectious and can cause heart and brain damage, while diseases such as gonorrhoea and chlamydia can lead to infertility and chronic abdominal pain. Not only do STIs affect a person’s physical wellbeing and further increase the risk of HIV infection, but the stigma attached to STIs can result in social isolation.

In 2015, the rate of syphilis among Aboriginal and Torres Strait Islander peoples was over six times higher than that of the non-Indigenous population, and in some remote areas, this rate rose up to a staggering 132 times higher. Indeed, almost 80 per cent of STIs among Indigenous Australians are found in remote communities, and a number of underlying risk factors such as poor access to health services, culturally inexperienced clinical staff, and a particularly young population contribute to such high infection rates.

In recent years we have seen significant progress in both the diagnosis and treatment of STIs and other preventable diseases. However, a syphilis outbreak across northern Australia has recently caused the number of STIs to rapidly rise and has already led to the death of at least four Indigenous Australians. This is completely unacceptable.

These statistics, while incredibly concerning, highlight a growing problem facing Indigenous Australians when it comes to their sexual health and wellbeing. It is clear that urgent action must be taken to address the high rates of STIs in Indigenous communities.

The Federal Government has shown some promise in addressing sexual health issues in Indigenous communities, by forming a Multi-jurisdictional Syphilis Outbreak Working Group to help prevent disease transmission and outbreak, and supporting the South Australian Health and Medical Research Institute to partner with the Aboriginal Nations Torres Strait Islander HIV Youth Mob to deliver awareness and education campaigns to Indigenous Australians across the country.

Yet, in March 2017, the Government confirmed the inexplicable scrapping of federal funding for both the Northern Territory AIDS and Hepatitis Council and the Queensland AIDS Council, all without conducting any community consultations or directly evaluating the programs themselves. For more than two decades, both services have delivered vital sexual health programs to remote and regional communities that experience difficulties accessing mainstream health services, and have developed close relationships with the communities that they serve. The cut in federal funding is set to bring these programs to an unfortunate and indefinite close, but it is services like these that play a key role in improving sexual health outcomes for Aboriginal and Torres Strait Islander people.

Living with a sexually transmitted disease is not just an individual health issue, but one that can impact the entire community. As HIV and STI rates for Aboriginal and Torres Strait Islander people continues to rise, we should not be cutting existing services aimed at improving sexual health practices in Indigenous communities.

The AMA understands that the Government has confirmed it will undertake an evaluation of a $24 million funding proposal to address STIs in Indigenous communities through eliminating syphilis, preventing HIV, health education, and STI screenings through outreach in vulnerable regions. However, we also understand that an outcome on this evaluation has yet to be announced.

The AMA would like to see the Government invest in areas to support ongoing efforts to address Indigenous sexual health problems, and ensure that culturally safe health care remains accessible to all Aboriginal and Torres Strait Islander people to help control the spread of STIs.

Commitment to safety and quality or new cuts to Commonwealth hospital funding?

BY ASSOCIATE PROFESSOR SUSAN NEUHAUS, CHAIR, HEALTH FINANCING AND ECONOMICS COMMITTEE

A key focus of the Health Financing and Economics Committee (HFE) is the pricing and funding of public hospitals.

Public hospitals are a critical part of our health system but remain historically and chronically underfunded. They struggle to manage the demands of aging populations, the burden of chronic disease and new technologies and treatments.

At the April 2016 COAG meeting, the Commonwealth committed an extra $2.9 billion to hospital funding. At the same time they secured State and Territories agreement to:

“Incorporate safety and quality into the pricing and funding of public hospitals services with the aim of improving health outcomes, avoid funding unnecessary or unsafe care and decrease avoidable demand for public hospital services.” (IHPA, Consultation Paper on the Pricing Framework for Australian Public Hospital Services 2018-19 p4)

In February 2017, the Commonwealth Minister for Health directed the Independent Hospital Pricing Authority (IHPA) to reduce the level of Commonwealth contribution to activity based hospital pricing for:

i. Sentinel events;

ii. Hospital acquired complications (HACs); and

iii. Avoidable readmissions.

The events listed in each category are developed by the Australian Commission on Safety and Quality in Healthcare. See Sentinel Events List of Hospital Acquired Complications (HACs). The list of avoidable readmissions is due for release later in 2017.

The Independent Hospital Pricing Authority Consultation Paper on the Pricing Framework for Australian Public Hospital Services 2018-19 detailed implementation timeframes and pricing adjustment methodology for the three categories of safety and quality events.

1 July 2017 Sentinel events will not be funded.

1 July 2018 HACs funding will be reduced by a patient “risk adjusted” factor.

1 July 2018 Avoidable hospital readmissions funding will be reduced.

The AMA supports sensible and well-considered initiatives to improve safety and quality in our public hospitals. The AMA wants to see a reduction in HACs and avoidable readmissions but does not endorse the use of Commonwealth financial penalties as an effective way to achieve this. Adverse outcomes result from a complexity of patient and institution factors. If hospitals are overstretched and under-resourced, errors are more likely to occur and less likely to be recognised or remediated.

Safety and quality funding penalties will not assist these hospitals to lift performance. It will instead entrench a spiralling decline in the hospital’s capacity to undertake the internal changes needed to focus on safety and avoid future penalties.

The HAC list

The HFE Committee also questioned the validity of some of the HACs that will incur a financial penalty. Examples include:

i. Malnutrition – Patients admitted to hospital with pre-existing skin eruptions that have, with exclusion of other causes, been diagnosed in hospital as nutrition related. The hospital should not be financially penalised for diagnostic accuracy;

ii. Respiratory complications – aspiration pneumonia. Superficially this seems a reasonable HAC inclusion except it may occur through no negligence, for example as a non-preventable consequence of “grand mal” fit;

iii. Gastrointestinal bleeding – A patient with gastric bleeding secondary to biopsy of melanoma metastasis. While bleeding in this setting is an identifiable risk, it was not avoidable; and

iv. Delirium is another poorly defined HAC that should be excluded.

Patients are unique and respond to treatment differently. Unless a root cause analysis is undertaken it will not be possible to justifiably attribute the event or apportion all of the adverse consequence to “poor or mismanaged public hospital care”.

The timeframe before HAC penalties take effect from 1 July 2018 is too rushed. A three to four month HAC shadow data collection (July–Sept 2017) will not permit reliable indications of financial impact on jurisdictions or identify unintended negative outcomes for patients as hospitals adapt to the financial penalty risks.

We raised similar concerns about the rush to penalise public hospitals for avoidable readmissions from 1 July 2018. The AMA wonders how genuine the planned stakeholder consultation will be given the avoidable admissions list will not be known until late 2017 and IHPA must report to COAG before they meet on 30 November 2017.

The AMA wants to see significantly less HACs and genuinely avoidable readmissions in public hospitals but does not endorse the rushed, bizarre notion that financial penalties will lead to a positive culture of hospital improvement in a severely underfunded and chronically overloaded system. Safety and quality improvement is more likely in “no blame” hospital reporting cultures such as those adopted in Norway and Denmark and recommended in 2014 by the European Commission. I have grave concerns that much of the progress public hospitals have made to date in areas of open reporting and transparency will be lost in the move to a defensive, financially penalised performance system.

Supervisors – powerhouses of the medical workforce

By AMA VICE PRESIDENT DR TONY BARTONE

I recently had the opportunity to reflect momentarily on how our well-oiled training allows us to so confidently and expeditiously care for our patients in a vast array of situations. One of my colleagues in the clinic had to attend to a patient with chest pain in the treatment room, something most of us have had to deal with. Making sure he did not need extra assistance, I observed the calm yet confident manner with how he dealt with the critical situation.

We can do all of those things because of our medical training and education, the clinical and professional skills we learned from working with dedicated supervisors, who in many cases become our mentors and friends.

The standard of medicine practised in Australia is consistently ranked among the best in the developed world. This is because we have a highly trained medical workforce based on the established apprenticeship model, with our Colleges maintaining education and independently determined training standards.

However, this model which has served us so well in the past is now at risk. Insufficient postgraduate positions and increasing numbers of graduates and aspiring trainees are stretching the system.

Continual advocacy by the AMA has ensured that there is a growing awareness that we do not have enough prevocational and specialist training places for the increasing number of new doctors. Whether governments and health policymakers are fully awake to the urgency of these worsening shortages is a topic for another time.

Unfortunately, I think it’s forgotten sometimes that clinical supervisors are the powerhouses of our apprenticeship model of training doctors. For the AMA, it is clear that to meet the challenge of training the expanding medical workforce, more clinical supervisors need to be found, supported and properly recognised and rewarded.

Boosting supervision capacity is a pivotal issue for our doctors in training, and the AMA has developed a significant suite of policy proposals and ideas in recent years.

To assist our ongoing advocacy, the AMA, led by the Medical Workforce Committee, has prepared a position statement that brings together these policies into a stand-alone document.

Building Capacity for Clinical Supervision in the Medical Workforce 2017 affirms our view that training and supervising new doctors is just as important as delivering services in the health system.

The document emphasises that the apprenticeship model of medical training is as relevant as it was as five decades ago, and shows that building supervision capacity across the spectrum of public, private, general practice and rural settings has common and unique sets of challenges and solutions.

Any discussion on this issue should not neglect the importance of ensuring that clinical supervisors have the support they need to train the next generation of doctors, as well as fostering a culture within medicine that encourages teaching and training.

From a personal perspective, many of my colleagues and I have found supervising junior colleagues to be a demanding yet thoroughly rewarding experience, with much gained in return.

Regrettably, I hear from different sources that protected time is not always available for teaching and training and simply added onto other responsibilities. Worse still, I hear many stories of those who have ended their roles because of a lack of support time or resources. I also know of VMOs and staff specialists who are actively discouraged from setting aside time for these activities. This makes no sense at all. Surely, now is the time to be boosting, not diminishing support for our supervisors.

Building Capacity for Clinical Supervision in the Medical Workforce 2017 outlines what the AMA believes has to be done from the industrial, financial, regulatory and cultural perspectives. I encourage you to take a look.

advocacy/position-statements

COAG move on mandatory reporting welcomed

The Council of Australian Governments (COAG) Health Council has resolved to develop a nationally consistent approach to mandatory reporting provisions for health practitioners.

The move has been warmly welcomed by the AMA.

Federal and State and Territory Health Ministers have agreed to consult with practitioner and consumer groups, and develop a nationally consistent proposal for consideration at the next COAG Health Council meeting in November 2017.

The agreement follows months of lobbying and advocacy from the Federal and State AMAs, highlighted by discussions in face-to-face meetings between Health Minister Greg Hunt and AMA President Dr Michael Gannon in recent weeks.

Dr Gannon said that the AMA had always advocated for treating practitioners to be exempted from mandatory reporting requirements.

“Mandatory reporting laws deter health practitioners from seeking early treatment for health conditions that could impair their performance,” Dr Gannon said.

“We have advocated long and hard at both the federal and State level for changes the mandatory reporting provisions.

“It is an issue that the AMA and the whole medical profession feel passionately about. It affects every doctor, their families, their loved ones, and their colleagues.”

Delegates to the AMA National Conference in May were unanimous in seeking amendments to the mandatory reporting requirements under the National Law, so as to not dissuade medical practitioners from seeking necessary medical treatment or assistance.

The intention of the legislation was to ensure the protection of the public by requiring doctors and other health practitioners to report colleagues whose health was impaired.

But this created a barrier for health professionals to access health care, particularly in relation to mental illness. The lived experience of doctors’ health advisory services across the country confirms these fears.

“Mandatory reporting undermines the health and wellbeing of doctors,” Dr Gannon said.

“It is a tragic reality that doctors are at greater risk of suicidal ideation and death by suicide. This year we have lost several colleagues to suicide.

“While there are many factors involved in suicide, we know that early intervention is critical to avoiding these tragic losses.

“The AMA has identified that mandatory reporting is a major barrier to doctors accessing the care they need.

“The real work begins now. We need action from all our governments.

“The medical profession and the public need a sensible system that supports health practitioners who seek treatment for health conditions, while at the same time protecting patients.

“We urge all Health Ministers to work cooperatively to come up with an achievable agreed proposal at their next meeting.”

CHRIS JOHNSON

[Editorial] Pushing the boundaries in paediatric surgery

Aside from the difficult psychosocial aspects of illness in babies and children, paediatric surgery and paediatric surgical research face inimitable challenges. These include the consequences of anaesthesia and radiation exposure in children, the implications of long-term complications, and, in many cases, the necessity of long-term care despite the inevitability of a transition to adult services. Diseases requiring paediatric surgery are sometimes rare and heterogenous in nature, with complex cases requiring multidisciplinary management.

[Articles] Global, regional, and national disease burden estimates of acute lower respiratory infections due to respiratory syncytial virus in young children in 2015: a systematic review and modelling study

Globally, RSV is a common cause of childhood ALRI and a major cause of hospital admissions in young children, resulting in a substantial burden on health-care services. About 45% of hospital admissions and in-hospital deaths due to RSV-ALRI occur in children younger than 6 months. An effective maternal RSV vaccine or monoclonal antibody could have a substantial effect on disease burden in this age group.

Minister to co-chair Indigenous Suicide Prevention Committee

Indigenous Health Minister Ken Wyatt will co-chair a new steering committee working directly with Aboriginal communities to address Indigenous suicide prevention.

Mr Wyatt made the announcement as the Kimberley Suicide Prevention Trial begins detailed planning and delivery of potentially lifesaving initiatives across the region.

“This is where the rubber hits the road, working very closely at the community level, involving young people, families and elders,” the Minister said when attending a recent suicide prevention roundtable in Broome.

Mr Wyatt said he believed it was important in establishing a strong working partnership between local Aboriginal communities and the Commonwealth, especially through younger people.

“We now have a strong operational plan based around the communities, to bring promising and proven strategies together in liaison with local people, to make a difference on the ground,” he said.

The Minister praised a presentation by Kimberley Aboriginal Youth Suicide Prevention Forum members Jacob Corpus (aged 20) from Broome and Montana Ahwon (19) from Kununurra, and said young people must be supported to play key roles in reducing suicide.

“Both Montana and Jacob are incredible and inspiring young leaders who have helped identify key factors that impact on Kimberley youth, which the steering committee will now consider,” Mr Wyatt said.

He also recognised the importance of including young Aboriginal people on advisory groups, to help empower them to take up future leadership roles.

Youth forum recommendations included: support for emerging young leaders, positive role models and mentoring; teaching in school of local culture and country traditions; the dangers of drugs and alcohol, and the importance of resilience; and strong youth engagement and networking through sports, arts and local cultural activities.

The steering committee will be co-chaired by Kimberley Aboriginal Medical Service Deputy CEO Rob McPhee and will report to the Kimberley Suicide Prevention Working Group.

The Government has committed funding of up to $1 million per year over three years to June 2019 to the Kimberley Suicide Prevention Trial, to support suicide prevention activities developed by the working group.

The Minister for Indigenous Affairs, Senator Nigel Scullion, has also announced the Government will commit $10 million to expand nationally the suicide prevention trials conducted in WA over the past year.

The Critical Response Team (CRT) model involves trained crisis team visits to families affected by suicide and other traumatic events to co-ordinate support services to help them deal with loss and to build resilience by communities for communities.

Suicide rates among Indigenous people in the Kimberley region of Western Australia are among the highest in the world, according to the World Health Organization. During the period 2001–2010, age-adjusted suicide rates among Indigenous and non-Indigenous Australians were respectively 21.4 and 10.3 per 100 000 population per year.

The AMA remains committed to working in partnership with Aboriginal and Torres Strait Islander groups to advocate for government investment and cohesive and coordinated strategies to improve health outcomes for Indigenous people. The AMA recognises Aboriginal and Torres Strait Islander peoples are among the most disadvantaged groups in Australia, and experience high levels of mental ill health and low levels of social and emotional wellbeing.

To read more on the AMA’s position go to position-statement/aboriginal-and-torres-strait-islan….

MEREDITH HORNE

Drink and drugs, a time bomb for baby boomers

In both the UK and Australia, risky drinking is declining, except among people aged 50 years and older, new research has found.

Researchers at Flinders University and South London and Maudsley NHS Foundation Trust in England, published their findings in the BMJ, inAugust this year.

The authors believe that Western countries are sitting on a time bomb of health and social issues arising from drug and alcohol overuse among baby boomers, including a worrying trend for episodic heavy drinking in this age group.

“Alcohol is the most common substance of misuse among baby boomers which presents the most concern because of the larger number of users and wide range of negative consequences,” said Professor Ann Roche, Director of the National Centre for Education and Training on Addiction at Flinders University.

The research also found that this generational trend is not restricted to alcohol.

“Some of the pharmaceutical drugs such as opioids also have severe consequences associated with their use,” Professor Roche said.

In Australia, the largest percentage increase in drug misuse between 2013 and 2016 was among people aged 60 and over, with this age group mainly misusing prescription drugs.

However, people over 50 also have higher rates than younger age groups for both past year and lifetime illicit drug misuse (notably cannabis).

The authors are keen to highlight that this older age group’s alcohol and drug use presents specific issues that are not common in younger demographics.

“Ageing reduces the body’s capacity to metabolise, distribute and excrete alcohol and drugs, and older people are also more likely to have pre-existing physical or psychological conditions or take medicines that may negatively interact with alcohol and drugs,” Prof Roche said.

“There is also a reduction in lean body mass, resulting in higher alcohol-drug blood concentrations,” she said.

The authors of the research are calling for a coordinated international approach to manage this rapidly growing problem, including treatment programs adapted for older people with substance misuse rather than those aimed at all age groups.

“There remains an urgent need for better drug treatments for older people with substance misuse, more widespread training, and above all a stronger evidence base for both prevention and treatment,” they state in the BMJ editorial.

Dr Rao and Professor Roche said the growing influence of baby boomer substance misuse will continue to present challenges for healthcare service delivery for older people.

The study also notes that it is an additional concern the increasing proportion of women drinking in later life, particularly those whose alcohol consumption is triggered by life events such as retirement, bereavement, a change in home situation, infrequent contact with family and friends, and social isolation.

The AMA questioned the priorities of the recently released National Drug Strategy 2017-2026, noting whilst alcohol in Australia is associated with 5,000 deaths and more than 150,000 hospitalisations each year, the Strategy puts it as a lower priority than ice.

AMA President Dr Michael Gannon said he believes support and treatment services are severely under-resourced, even though the costs of untreated dependence and addictions are staggering. Alcohol-related harm alone is estimated to cost $36 billion a year.

The broader community impacts of those affected by dependence and addictions are more likely to have physical and mental health concerns, and their finances, careers, education, and personal relationships can be severely disrupted, Dr Gannon said.

The AMA’s Harmful Substance Use, Dependence, and Behavioural Addiction (Addiction) 2017 Position Statement can be read at position-statement/harmful-substance-use-dependence-and-behavioural-addiction-addiction-2017.

MEREDITH HORNE

Communiqué from Federal Council meeting 17-18 August 2017

BY DR BEVERLEY ROWBOTHAM, CHAIR OF FEDERAL COUNCIL

Welcome to the inaugural communiqué from Federal Council highlighting the debates had, and decisions taken, at its meeting in Canberra in the depths of winter on 17-18 August.

In giving his report, AMA President Dr Michael Gannon made mention of the many recent advocacy wins of the AMA. He reported that the working relationship with the Federal Government has evolved following the compact agreed at the time of the Federal Budget in March, enabling frank and effective engagement with Health Minister Greg Hunt.

Dr Gannon reported that benefits of this engagement can be seen in recent successes with the Minister moving to scrap the draft national maternity services framework which was opposed by the AMA for lack of obstetrician and GP involvement; and support by Minister Hunt to work with State and Territory colleagues to remove mandatory reporting from the National Law. Advocacy on this latter issue has been strongly supported by Federal, State and Territory AMAs, which uniformly endorse the WA approach to mandatory reporting.

The Secretary General’s report provided a comprehensive overview of the AMA’s medico-political advocacy. The Secretary General Anne Trimmer noted that the Governance Institute’s 2016 Ethics Index, with research undertaken by IPSOS, ranked the AMA as the most ethical of the national membership and industry associations.

She reported that the secretariat is working with the Minister’s advisers and the Department of Health to shape appropriately targeted after hours GP services, arising from the draft MBS Review report into these services. The secretariat is working with the NBN to finalise criteria for improved access to broadband in rural areas with a proposal to grant Public Interest Premises status to medical practices under the satellite footprint.

Two of Federal Council’s committees are working with the secretariat to develop a new advocacy strategy for aged care with funding and technology identified as priority areas. Federal Council also agreed to campaign for additional funding for the incoming Practice Incentive Program Quality Incentive and strongly opposed recently flagged proposals to increase the return of service periods for future bonded medical places program participants.

The Federal Council noted updates on the two major government reviews currently underway, the MBS Review and the Private Health Ministerial Advisory Committee review of private health insurance arrangements. An informal grouping of approximately 30 members is working with the AMA to inform its response to the draft reports. Work on the PHMAC review has slowed over the winter period although a new working group on risk equalisation has been established. The AMA will be advocating for changes to the risk equalisation pool to facilitate coverage OF pregnancy under all levels of PHI cover.

Federal Council discussed the Government’s review of the medical indemnity schemes. The AMA has worked closely with the Department of Health to shape the terms of reference and remains strongly committed to the schemes as an effective mechanism to moderate the cost impact on practices and patients. The AMA has been communicating to the profession the need for active engagement in the review by Colleges, Associations and Societies.

The AMA is represented on a small working group to review the Health Professional Online Services (HPOS) system, which emerged as vulnerable to fraud. The Minister for Human Services, Alan Tudge, kept the President informed of the steps taken to ensure integrity of the system prior to the establishment of the review of health provider access to Medicare numbers.

With a Senate inquiry underway into the value of private health insurance and medical out of pocket costs, the Federal Council set aside a policy session to consider the issues in depth. The AMA lodged its submission at the end of July (the submission can be read at submission/submissions-out-pocket-costs-australian-he…).

The submission included data on billing practices collected from a poll of members.

Federal Council, noting the growing public commentary calling on limits on out of pocket medical expenses, agreed that the priority was to correct misleading statements about the role of doctors’ fees in the debate about affordability of health care. An animated debate ensued with Councillors contributing a range of views based on their personal experience.

The issue has been largely driven by private health insurance and the growth in gaps in coverage and exclusions. Federal Council noted that there had been limited complaints to the Private Health Insurance Ombudsman about out of pocket expenses. Federal Council also noted that many medical services had always had an element of out of pocket contribution, not to be confused with the charging of an excessive fee which the AMA strongly opposes. Federal Council agreed that there needs to be greater clarity on what constitutes an excessive fee and that this needs to be clearly communicated to the public.

The President acknowledged the comments of Federal Council and noted that he had an opportunity to address these issues in his upcoming address to the National Press Club (the transcript of the President’s address can be read at media/dr-gannon-national-press-club-address-0).

The AMA’s work on public health initiatives continues, ranging from road safety to obesity and physical activity. Federal Council heard progress reports from working groups led by Councillors and debated draft position statements on road safety, obesity and physical inactivity. Other working groups are considering nutrition, mental health and the social determinants of health. A revised position statement on mental health is in development in conjunction with the AMA psychiatrists’ group.

Federal Council received reports from each of its practice group councils, and from its committees. The State and Territory AMAs and Australian Medical Students’ Association provided reports on current areas of advocacy.

Questions asked and answered during Press Club appearance

In addition to delivering a wide-ranging 30-minute speech at the National Press Club, AMA President Dr Michael Gannon spent another half hour at the podium fielding questions from the Canberra Press Gallery.

The issues raised by the inquiring reporters ranged from doctors’ fees, to refugee health, to codeine prescriptions, to marriage equality – and a whole lot in between.

On the subject of cost-shifting by the States to patients covered by private insurance who are attending public hospitals, Dr Gannon said he had made the point directly to Health Minister Greg Hunt, that flexibility must be maintained.

“We don’t want a situation where insured patients are prohibited from care in public hospitals,” Dr Gannon said.

“They might live in a rural area where there’s no alternative; no fancy, shiny, private hospital there in the region. It might be the case that a doctor with sub-specialist expertise only works in a public hospital. It may be that they need the intensive care unit that only exists in a public hospital. It may simply be the patient’s choice. So, wherever we land, we must end up with flexibility.

“One of the things that’s led to this problem is the fact that the States and the Territories and the Commonwealth have underinvested in public hospitals. So, the public hospitals are looking for new revenue streams, and sometimes they’re a bit too tricky and clever trying to get hold of insured patients when they’re not actually providing any greater level of care.

“But I also think this is an area where the private health insurers need to step up to their part of the responsibility.”

In his speech, Dr Gannon described the push by insurers for doctors to publish their fees and customer referrals as “dangerous territory”.

In response to questioning about that, he said informed financial consent was very important.

“But I don’t trust a website owned by the insurers to produce un-vetted information about the quality of the magazines in the waiting room, whether or not the receptionist was rude, and I have great concerns about people not being able to obviously interpret quality data,” he said.

“It’s a lot more complicated than a cheesy website might appear.”

Drug testing welfare recipients

The AMA President was highly critical, when he was asked about it, of the Government’s plan to drug test welfare recipients.

“If I had to put a nasty star on the Government’s last Budget, it was this mean and non-evidence-based measure. It simply won’t work,” Dr Gannon said.

“This is not an evidence-based measure (and) will not help. We don’t expect people in most industries to have drug testing before they turn up to work.

“It’s simply unfair and it already picks on an impaired and marginalised group. It’s not evidence-based. It’s not fair. And we stand against it.”

NDIS

On the question of the NDIS eligibility of people with mental health conditions, Dr Gannon said the scheme needed certainty of funding to ensure proper access and eligibility.

“This is going to be a very difficult and vexed issue for Governments now going forward,” he said.

“Talk to the experts. Talk to the GPs, the psychiatrists, the psychologists, the carers who are there providing that care every day. Look at the evidence. Look at what works, and fund it according to what might be expected to work from international evidence, or from talking to home-grown experts here in Australia.”

Same-sex Marriage

On marriage equality, the President said he wouldn’t lecture parliamentarians on legislative approaches, but a risk existed that the wider discussion on the issue will have mental health impacts on people directly affected.

“Equally, we live in a democracy where people are entitled to have their say. I faced criticism of our Position Statement from within the membership, and I have made it very clear that we, as an organisation, are a broad enough church that we can accommodate different views on this topic,” he said.

“And I am not uncomfortable with the Australian people being given their say. We believe that this is an area of discrimination and therefore does have health impacts. We would like to see it resolved. We would like to see the Government, the Parliament, getting on in other crucial areas of public policy, but we are silent on the exact details about how we get there.”

Codeine prescriptions

On codeine, and the AMA’s agreement with the decision to make it available only by prescription, Dr Gannon said the AMA’s position was not a unilateral statement.

“This is very much the AMA supporting the Therapeutic Goods Administration, the TGA, in their independent science-based analysis of the issues,” he said.

“Now, many people might not know that there’s already 25 countries where codeine requires a prescription. Many people might not know that the science tells us that we all metabolise codeine very differently. So for a significant minority of us, we metabolise it in a way that is extremely potent, every bit as powerful as morphine, and is a common cause of death from opioid overdose.

“Not only have we told the Minister we support the TGA’s decision, we are also telling the State and Territory Health Ministers that we do not want to see exemptions from this. That’s wading into very, very dangerous territory, when the independent regulator looking at scientific evidence is overrun by an industry that has a different view.”

Euthanasia

On palliative care and support of doctors who may wish to assist patients to die, he was very clear.

“We have inadequate legislation in most parts of Australia to protect doctors acting ethically and lawfully with inadequate doctrine of double effect legislation,” Dr Gannon said.

“Ninety-nine per cent of end-of-life decisions do not involve requests to die. That is a very, very, very small part of the system.

“And surely the aspiration of all people, whether they favour voluntary euthanasia or not, is to improve palliative care services.

“The AMA Position Statement makes it extremely clear that we understand this is a decision for society: it’s Parliament’s, it’s legislators’. The AMA’s position is that doctors should not participate in these arrangements.”

Refugee health care

Regarding the level of health care provided to asylum seekers in offshore detention, Dr Gannon said the ethical principles were very clear.

People seeking the protection of the Australian Government are entitled to healthcare standards the same as Australian citizens.

“So, that’s a matter of ethics and that’s a matter of law. What we’ve developed over the past 12 months or so is a relationship with the Chief Medical Officer of the Department of Immigration and Border Protection, so that when we receive discussions on individual healthcare episodes we are able to talk about them,” he said.

“… a difficult and vexed issue where a form of medical care, namely termination of pregnancy – which could relatively easily be provided on Nauru – can’t legally be provided because it’s illegal on the island.

“That means that if that cannot be provided, that those patients must be transferred to the mainland. This is a hotly contested political issue. I am not an immigration expert. But I like to think I’m an expert in medical ethics, and I’ve stated our position very clearly as to the health standards that we would expect.”

Private health insurance

On private health insurance, Dr Gannon said agreement must be reached on basic level of cover, or at least better transparency, so people know what they’re covered for.

“The policies that are nothing more than to dodge the tax penalty, they’re junk,” he said.

“The policies that limit you to care in a public hospital, I need to be convinced why they’re any better than being a public patient in our excellent public hospitals.

“Now I don’t want to spend my entire life arguing with the insurers. They have a right to make a profit. In fact they’ve got a corporate responsibility to deliver a profit. But they cannot deliver that profit on the back of diminished services to private patients. And if they don’t get it and they don’t get it soon, they will drive their industry off the cliff.”

CHRIS JOHNSON

The full transcript of Dr Gannon’s Q&A session at the National Press Club can be found here:

media/dr-michael-gannon-national-press-club-q-and