AMA demands urgent fix to humanitarian emergency on Nauru

AMA demands urgent fix to humanitarian emergency on Nauru

The AMA has called on the Government to urgently transfer refugee families from Nauru, describing the situation there as a humanitarian emergency.

In a letter to Prime Minister Scott Morrison, AMA President Dr Tony Bartone urged a policy rethink and demanded that asylum seeker children and their families be removed from Nauru as a matter of priority.

Dr Bartone said deteriorating physical and mental health among refugee children and their families meant they should be relocated to more appropriate places, preferably in mainland Australia.

“Put bluntly, we want some urgent action to help these vulnerable people who find themselves in a hopeless, despairing situation,” Dr Bartone wrote in his letter to the PM.

“The AMA has been calling for a more humanitarian approach, including independent assessment of health care arrangements, for many years now.

“The medical situation for the children on Nauru has been described by health experts, including medical staff who have worked on Nauru, as critical and getting worse. It is a humanitarian emergency requiring urgent intervention.

“We have been given some hope at the bureaucratic level, but a slammed door at the political level.

“The AMA and the medical profession are demanding a change of policy – a change of policy that reflects community concern for the health of asylum seekers.”

Dr Bartone said the AMA wants to see a more compassionate Government approach to the health care of refugees and asylum seekers in the care of the Australian Government.

He said there had been a recent groundswell of concern and agitation across the AMA membership and the medical profession about conditions on Nauru and the escalation in reports of catastrophic mental and physical health conditions being experienced by the asylum seekers, especially children.

“As a suburban Melbourne GP for more than 30 years, and a grassroots Australian with strong community connections and Christian values, I passionately believe we can and must do more to look after the health of these people, many of whom have fled war, conflict, or persecution,” he wrote.

“There are now too many credible reports concerning the effects of long-term detention and uncertainty on the physical and mental health of asylum seekers.

“It is within the power of the Government to move on this issue and play its part in allowing traumatised people to begin rebuilding their lives.

“Australia is a caring nation with a long history of compassion and respect for human rights. We need to show the Australian people and the world that we are still a caring nation.

“The AMA believes that asylum seeker children and their families on Nauru must be removed and given access to physical and mental health care of an appropriate standard.”

Dr Bartone repeated the AMA’s call for the Government to facilitate access to Nauru for a delegation of Australian medical professionals to assess the health and welfare of child refugees and asylum seekers.

“This includes access to the children and their families and/or carers, the International Health and Medical Services (IHMS) medical professionals administering to the children, and any Nauruan Government officials administering to the children,” he said.

“Membership of the delegation would be determined in consultation with the AMA and the delegation would make public the findings of its inspections and interviews to assure the Australian public that the Australian Government has done all that is possible to protect the health and wellbeing of asylum seekers and refugees.”

In a separate letter to all MPs and Senators urging support and advocacy for the AMA position, Dr Bartone reminded politicians that, in April 2017, the Senate Legal and Constitutional Affairs Committee released the report of its inquiry into asylum seekers on Nauru.

The inquiry made two recommendations about the availability of medical services and medical transfers:

Recommendation 1: The committee recommends that the Department of Immigration and Border Protection, as a matter of urgency, commission an external review of its medical transfer procedures in offshore processing centres.
Recommendation 2: The committee recommends that the Australian Government undertake to seek advice in relation to whether improvements are required to the medical treatment options available to asylum seekers and refugees in the Republic of Nauru and Papua New Guinea, particularly mental health services.

The Government has not yet responded to the inquiry.

Dr Bartone praised the hard work and dedication of doctors and health workers who have been providing care with IHMS on Nauru.

“These health professionals and their employer have been doing their best in very trying conditions in isolation – and under a veil of secrecy not of their doing,” Dr Bartone said.

“The Government must get fair dinkum and give these long-suffering asylum seeker children, many of whom are extremely ill, and their families a fair go – bring them to Australia for proper care in the best possible environment for their severe mental and physical health conditions.”

There are about 100 children on Nauru. Many have been in detention long-term. Media reports suggest about 20 of the children are refusing food and fluids.

CHRIS JOHNSON

Needless treatments: antipsychotic drugs are rarely effective in ‘calming’ dementia patients

Antipsychotic medications were initially developed to treat schizophrenia, a mental health condition characterised by psychotic symptoms such as delusions and hallucinations. Because of their sedative effects, antipsychotic medications (such as risperidone, olanzapine, quetiapine and haloperidol) are often used to “manage” people with dementia.

People with dementia often experience a range of psychological symptoms and behaviour changes. These can include anxiety, sleep disturbance, pacing, wandering, crying out, agitation, delusions and hallucinations.

These are referred to as “behavioural and psychological symptoms of dementia” (BPSD) though the term “responsive behaviours” has also been adopted to help explain their cause, signalling that there are often reasons behind the behaviours. Understanding and treating these reasons is the best way to approach these behaviours.

Antipsychotic medications are known as psychotropic medications. These are drugs that alter a person’s mental state and include antipsychotics, antidepressants, benzodiazepines and anticonvulsants, which are also used to sedate patients in nursing homes. These come with significant and serious risks. Clinical guidelines recommend such medications be used only as a last resort.

Psychotropic medicines should only be considered when non-pharmacological interventions have failed and the patient has symptoms that are distressing for them, their family or fellow residents.

Responsive behaviours

Dementia is not just a single disease. It’s a term describing symptoms associated with more than 70 separate diseases, including Alzheimer’s disease and Lewy body dementia. The condition affects many brain functions including language, personality and reasoning skills, not just memory, which is usually associated with the condition.

Responsive behaviours in people with dementia vary according to the type and severity of their disease. They also fluctuate over time. A Canadian study of 146 aged care residents assessed these behaviours monthly for six months, revealing a wide variation in their duration and frequency. Results showed most responsive behaviours lasted for less than three months with usual care.

Many responsive behaviours in people with dementia are thought to result from, or be worsened by, unmet needs (pain, hunger), the environment (over- or under-stimulation), social needs (loneliness or need for intimacy) and approaches of carers or others. Sometimes these behaviours are caused by an acute medical illness on top of the dementia, such as an infection. Other times the behaviours arise from the disease process of dementia itself.

Each cause requires different treatment. For example, an infection shouldn’t be missed, nor should pain, each requiring different strategies. So, the first step for those around the person, both health care professionals and family carers, is to work out why they are behaving a certain way rather than reaching for a script pad.

Psychotropic use in aged care

Psychotropic medications are often over-used. The main evidence for excessive use of psychotropics such as antipsychotics in dementia in Australia has been collected in aged care homes. A recent study, that one of the authors was involved in, examined antipsychotic use in 139 homes across all six states and the ACT during 2014-2015. It assessed the use of antipsychotics in more than 11,500 residents.

We found that 22% of residents were taking an antipsychotic medication every day. And concerningly, more than 10% of residents were charted for a “when required” antipsychotic. This means they could be given an antipsychotic dose when a behaviour occurred that their carer decided was necessary to medicate, or a top-up dose in addition to their regular dose.

Excessive use of antipsychotics in older people does not appear to be confined to the residential aged care sector. A 2013 district nursing study of 221 people with dementia living in their own homes found that 18% were prescribed these medications.

Many trials have examined the effectiveness of antipsychotics to treat agitation in people with dementia. These studies show they only offer benefit to about 20% of people with these symptoms and appear to offer no benefit for other responsive behaviours such as wandering, crying out or anxiety.

But what’s worse is that use is associated with severe adverse effects including stroke, early death, infections, Parkinson’s-like movement disturbances, falls and over-sedation.

There are times when behaviours can be severe and disabling and impact the quality of life for the person with dementia. Sometimes the behaviours may put the person or others at risk. In these cases, careful prescribing is recommended. When needed for responsive behaviours, antipsychotics should be taken at the lowest effective dose for a maximum of three-months.

If people are in pain, it is absolutely essential that this is treated. One study showed using increasingly strong analgesia was as effective in treating agitation in dementia as antipsychotics.

Advice for family members

Family members need to understand and be aware of these symptoms and behaviours, their treatment and alternatives and be part of finding out why they are happening as well as the solution.

This includes being aware that legally, psychotropics must be prescribed with consent, either from the person themselves or from their substitute decision-maker. Families should not just be finding out about use of medications when they receive the pharmacy bill.

Skilled advice for nursing homes is available across Australia, 24-hours a day from the Dementia Behaviour Management Advisory Service and the Severe Behaviour Response Teams. They support aged-care providers in improving care for people with dementia and related behaviours.

Families need to make sure that the facility their loved one resides is in is aware of and uses this service, so they don’t have to resort to using drugs first. The 24-hour helpline number is 1800 699 799.

For more information about your rights, visit empoweredproject.org.au

Juanita Westbury, Senior Lecturer in Dementia Care, University of Tasmania and Carmelle Peisah, Clinical Associate Professor, University of Sydney

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

[Comment] Strengthening oral health for universal health coverage

The Global Burden of Disease Study 2016 estimated that oral diseases affected half of the world’s population.1 Nonetheless, oral health is a neglected area of global health that could make a contribution to achieving universal health coverage (UHC).2 UHC can help frame policy dialogue to address weak and fragmented primary oral health services, and address substantial out-of-pocket expenses associated with oral health care in many countries, which in turn would help to achieve UHC.

Push to reduce unnecessary colonoscopies

A new Colonoscopy Clinical Care Standard has been launched by the Australian Commission on Safety and Quality in Health Care and will benefit millions of Australians seeking treatment.

It is the first nationally agreed standard of care for patients undergoing a colonoscopy.

The number of Australian who have a colonoscopy each year is approaching one million. Despite it being frequently performed, it is a complex medical procedure and should only be offered if the benefits outweigh the risks.

Undergoing the procedure unnecessarily doesn’t make sense and may extend the wait time for those who do need it, according to the new standard.

In launching the new standard in Brisbane during Australian Gastroenterology Week in September, the Commission said patients with a positive bowel cancer screening result should consult their general practitioner to discuss further investigation. In many cases this will be a colonoscopy.

The procedure examines the large bowel (colon) to diagnose and treat a range of bowel diseases including bowel cancer, the second most common cancer diagnosed in both men and women in Australia. Bowel cancer is expected to claim more than 4,000 lives in Australia in 2018.

The Commission’s Clinical Director Professor Anne Duggan said the new standard offers guidance to patients, clinicians and health services at each stage of a colonoscopy, with the goal of ensuring high-quality and timely colonoscopies for patients who need them. The standard will also help to reduce the number of unnecessary colonoscopies being carried out.

“The Commission’s Australian Atlas of Healthcare Variation 2015 found stark differences across the country in rates of colonoscopies being performed, with some areas having colonoscopy rates 30 times higher than others,” Professor Duggan said.

“Colonoscopy rates were significantly higher in capital cities and lower in remote areas. In major cities, rates were lower in areas of low socioeconomic status. The clinical care standard supports clinician certification and recertification as requirements for colonoscopy services, and will bring increased rigour to the procedure and shine a light on when and how these procedures are done.

“We asked experts in colonoscopy about how to look after people in the best possible way and used this information to develop guidelines for everyone involved.”

Gastroenterological Society of Australia (GESA) spokesman Dr Iain Skinner is a colorectal surgeon and advanced colonoscopist who co-chaired the Commission’s working group that developed the new standard. He said the guidelines were much needed.

“The clinical care standard further enhances care, focusing on bowel preparation, sedation, the colonoscopy and recovery. The standard also clarifies appropriate use of the procedure based on evidence,” Dr Skinner said.

“This is an advanced procedure and we don’t want it being performed unnecessarily. Fewer unnecessary colonoscopies will free up access to more timely colonoscopies for those who are at moderate or high risk, such as those with a history of polyps or a significant family history of bowel cancer, or those who return a positive bowel screening test.”

The Colonoscopy Clinical Care Standard and separate fact sheets for consumers and clinicians can be found on the Commission’s website at: https://www.safetyandquality.gov.au/our-work/clinical-care-standards/colonoscopy-clinical-care-standard/

TB and HIV – still miles to go

BY PROFESSOR STEPHEN LEEDER, EMERITUS PROFESSOR PUBLIC HEALTH, UNIVERSITY OF SYDNEY

In 1966, we junior interns at Sydney’s Royal North Shore Hospital were accommodated at Lanceley Cottage. It lay just beyond the thoracic unit, where patients with active TB were treated on the top floor. Their medication included PAS (para-aminosalicylic acid) – not liked because of its volume or its aspirin-like taste. Walking to the main hospital each morning, we had to dodge the PAS ‘rain’ from disgruntled patients as they tipped their daily dose over the balcony. Compliance with treatment, even in hospital, has been a problem for as long as effective chemotherapy has been available.

Human tuberculosis has been around for at least 5,000 and perhaps 9,000 years. The mycobacterium shows great resilience. If it had been listed on the stock exchange, it would have yielded a high dividend with few interruptions. Most recently, it has settled into the communities where HIV/AIDS is prevalent, adding to the burden of misery.

Nor is it limited to humans. As Wikipedia points out: “Seals and sea lions that bred on African beaches are believed to have acquired the disease and carried it across the Atlantic to South America.”

Like HIV, TB’s victims are often young, triggering art and poetry to lament the loss (see the photo above of a painting by Cristobal Rojas, himself suffering from TB at the time of this painting).

On September 26 this year, a high-level meeting of the UN will convene in New York with the theme “United to end tuberculosis: an urgent global response to a global epidemic”. High-level meetings attract heads of state and are rare events for health. Previous meetings have considered HIV (2011) and non-communicable disease (2014). So this is big ticket.

As with most top-drawer international diplomatic events, the UN meeting has been preceded by much hammering out of the agenda. For example, In November last year, the Moscow Declaration to End Tuberculosis was agreed to by 75 ministers of health. Strong on rhetoric, but also substantial, it aimed to promote multi-sectoral action (never forget that TB thrives in impoverished societies), “track progress, and build accountability – signalling a long overdue global commitment to stop the death and suffering caused by this ancient killer”.

The WHO provides the following facts about TB:

In 2016, 10.4 million people became ill, and 1.7 million died from it (including 400,000 among people with HIV). More than 95 per cent of deaths occur in low- and middle-income countries;
Seven countries account for 64 per cent of the total cases, with India leading the count, followed by Indonesia, China, Philippines, Pakistan, Nigeria and South Africa;
In 2016, an estimated 1 million children became ill and 250,000 children died (including children with HIV-associated TB); and
It’s a leading killer of HIV-positive people: in 2016, 40 per cent of HIV deaths were due to TB. HIV increases the risk of TB 20-30 fold.

In some places, TB has become resistant to isoniazid and rifampicin, two major treatments, and to other drugs as well. Fortunately, new diagnostic methods can rapidly detect multi-drug resistant (MDR) TB, enabling shorter and probably more efficacious treatment regimens. The magnitude of MDR-TB is seen in the claim that only a quarter of infected people are currently detected and fewer are adequately treated.

Earlier this month, the WHO announced changes to drug-resistant treatment regimens.

Using available high-quality evidence, a new priority ranking of the medications has been proposed, such that treatment is based on a careful balance between expected benefits and harms.

The second important change is a fully oral regimen as one of the preferred treatments for MDR-TB, with injectable agents to be replaced by more potent alternatives such as bedaquiline (the first-ever medicine to be developed specifically for MDR-TB).

“The treatment landscape for patients with MDR-TB will be dramatically transformed for the better,” said Dr Soumya Swaminathan, WHO Deputy Director-General for Programmes.

“WHO has moved forward in rapidly reviewing the evidence and communicating the changes needed to improve the chances of survival of MDR-TB patients world-wide. Political momentum now needs to urgently accelerate, if the global crisis of MDR-TB is to be contained.”

While TB is yielding to effective new treatments such that it is possible to envision a day when it has been eliminated, no such confidence can be applied to HIV.

The August 2018 report from UNAIDS, Miles to Go, http://www.unaids.org/sites/default/files/media_asset/miles-to-go_en.pdf draws attention to stalling in the program to reduce the incidence and prevalence of HIV and AIDS. It speaks critically of ‘complacency’: in 2017, 180,000 children became infected. One million people die of HIV/AIDS related illnesses each year. But we must balance these disturbing figures against a remarkable achievement with treatment: 22 million people are on anti-HIV drugs.

It is at the intersection of HIV and TB that urgent action is needed. As Michel Sidibé, who comes from Mali and serves as Executive Director of UNAIDS, the Joint United Nations Programme on HIV/AIDS, and as Under-Secretary-General of the United Nations, writes in the Foreword to the UNAIDS report,

“The upcoming United Nations High-Level Meeting on Tuberculosis is a huge opportunity to bring AIDS out of isolation and push for the integration of HIV and tuberculosis services. There have been major gains in treating and diagnosing HIV among people with tuberculosis, but still, decades into the HIV epidemic, three in five people starting HIV treatment are not screened, tested or treated for tuberculosis, the biggest killer of people living with HIV.” (Mr Sidibe’s attention has recently been rather distracted by sexual harassment concerns.)

So, with TB and HIV we have achieved much – not only in Australia, where we are blessed with the necessary prosperity to detect and treat, but also globally and in poorer countries.

To bridge the remaining gaps, we require money, committed people, political enthusiasm and broad vision. Several Australian doctors and nurses are making major contributions to the control of TB and HIV throughout Asia and elsewhere. Let’s salute them while realising there is space for more to join them.

Further background: BMJ, Revisiting the timetable of tuberculosis https://www.bmj.com/content/362/bmj.k2738

Collaboration, not competition

BY DR RICHARD KIDD, CHAIR, AMA COUNCIL OF GENERAL PRACTICE

Team work in providing comprehensive and quality patient care is not a new concept. Within the medical profession, we recognise our professional limitations and operate only within our scope of practice. When needed, we seek the opinion, or skills and expertise of other colleagues.

With an aging population and the rising incidence of chronic disease adding to the complexity of patient care, there is an enhanced focus on the role and importance of well-coordinated multidisciplinary health care teams. However, it is critical that these teams work effectively. Mutual respect for the skills and expertise of team members is fundamental, with each making their contribution within their scope of practice to meet the health care needs of the patient.

We all know the dangers to our patients of poorly coordinated, fragmented care. We also know that best practice care starts with the right assessment and diagnosis by a medical practitioner and, in the case of general practice, a longitudinal relationship with the patient. Despite this, we see ceaseless ambition of some pharmacist groups for prescribing rights and a greater role in the provision of health services, such as preventative health, disease screening and detection and chronic disease management.

For a GP, the community pharmacist, who is responsible for the dispensing and supply of medications, provides an important and complementary role in the delivery of quality patient care. Pharmacists are vital to the safe provision and use of medicines. They provide assurance that correct dosages are dispensed and that patients understand when and how to take their medications.

The AMA places a high value on the professional role of pharmacists working with medical practitioners and patients to: ensure medication adherence; improve medication management; and provide education about patient safety.

The AMA fully supports pharmacists undertaking roles within their scope of practices to support patient health care. But the community needs a clear understanding of how the core education and training differentiates medical practitioner and pharmacist scopes of practice.

Taking comprehensive histories, undertaking examinations, determining appropriate diagnostic investigations, making a diagnosis, and managing and treating a patient are the domain of the medical profession because that is what we, not pharmacists, are trained to do.

Certainly, the AMA recognises the benefits of integrating non-dispensing pharmacists into general practice to provide enhanced patient care. That is why we worked with the Pharmaceutical Society of Australia in developing such a plan that now, through the incoming Workforce Incentive Program, will see GPs and pharmacists supported to work even more collaboratively in the best interest of patients. With medical oversight, the current role of pharmacists may well expand to support a greater role in the provision of more holistic patient care. Patient wellbeing, after all, is a fundamental tenet of both our professions’ codes of ethics.

What we don’t want to see is patient care further fragmented, services duplicated, and access to the right care delayed. This simply causes undue costs to the health system and poor health outcomes for patients. What GPs and pharmacists should do is continue to work together respectfully, acknowledging the different skills and expertise we bring to the team for the patient. Our patients deserve collaboration, not competition, and policy makers must continue to avoid simplistic ideas that are driven by commercial needs and not good patient care.

Increasing the length of internship – what will we actually achieve?

BY DR CHRIS WILSON, CO-DEPUTY CHAIR AMA COUNCIL OF DOCTORS IN TRAINING

In 2015, a COAG review of Australian Medical Intern Training was completed. The intent of the review was to look at the internship model and assess if internship was producing “fit for purpose” clinicians. As part of the review, four models for change were proposed. Model A, the least revolutionary with no significant change to the structure but increased access to non-traditional settings including general practice, was the most preferred by doctors in training. Model B proposed shifting from a time-based internship to one focussed on specific mandatory skills and exposure to the “patient journey” and “different care contexts”. Models C and D were more revolutionary, with a proposed two year program either starting in the final university year or covering the first two postgraduate years.

As mentioned, the opinion of the AMA CDT and DiTs across the country at the time of the review was that, while there is always room for improvement, internship is not broken. Despite this, after the release of a COAG Health Council response to the review in July this year, we look to be pressing towards the two year model.

In a postgraduate world, internship commencing during university would be unworkable for obvious reasons, so the current preferred model is an internship covering PGY1 and 2.

While on the surface this looks like significant change, what does the second year actually achieve? There is agreement that general registration should be granted after successfully completing the first year, as it is now, so no change on the registration front. If it comes with increased opportunities for exposure to patients across the health spectrum and more structured learning, this will be to the advantage of doctors in training, the healthcare system and in the long run, our patients. It’s not clear though how this would be distinguishable from the current roles undertaken by PGY2 doctors. Changing the role title to ‘intern’ does not automatically reduce the service requirements and increase the educational value of rotations – someone still has to write the discharge summaries.

One potential benefit would be an expectation that all rotations are accredited as suitable training environments by a Medical Board delegate (like the Post Graduate Medical Councils). Thankfully, this already happens in most jurisdictions, however, there is a danger that without additional resources, regions where it is not standard to accredit beyond PGY1 could see their accreditation processes watered down to meet demand. Currently, the federal body responsible for the coordination of State/Territory-based accreditation bodies, the Confederation of Postgraduate Medical Education Councils, remains unfunded. It seems absurd for the Government to push for change in the makeup of internship yet not fund the body responsible for enacting it.

Should we move to a two year model, we would also expect doctors in training be able to obtain job surety over the period of internship in the form of a minimum two year contract. This would be a sign of good faith from employing health services that they intend to train and support their doctors in training during this transition period.

AMA CDT’s position in 2015 was that internship is not broken and that position remains unchanged. Without tackling the creep of increasing service need forcing education and training to become ancillary components of internship, it’s hard to see a second year bringing with it much improvement.

[Comment] Childhood mortality during conflicts in Africa

The International humanitarian law differentiates two types of armed conflicts: international (between states) and non-international (domestic).1 Since 1989, 75% of non-state armed conflicts have been in Africa.2 Children and women bear most of the burden of these events. Childhood deaths due to conflicts present a real threat to the achievement of the global target of ending preventable deaths of children by 2030.3 Despite the link between armed conflicts and direct deaths (combat-related) and indirect deaths (excess mortality because of worsening health disparities and disruption of basic health services), most assessments of childhood deaths done to date have not explicitly incorporated the effect of conflicts on child survival.

[Correspondence] Ebola Medals returned to the UK Government in protest

The UK’s hostile environment policies are being increasingly challenged, but within health care, charging regulations in the National Health Service (NHS) remain unchanged, and many migrants continue to fear seeking help when unwell. The October, 2017, amendments to these regulations brought in upfront charging, at 150% of the actual cost, before treatment, to anybody unable to prove their immigration status. This is applied to secondary care and various community services, and even pregnant women and children are charged.

Green light from Committee for Gold, Silver, Bronze, and Basic

The Federal Government’s proposed private health insurance policy reforms look set to become law this year after a Senate Committee recommended passing the Bills.

The Committee investigating the new Gold, Silver, Bronze, and Basic policy proposals made just one recommendation when it reported in the first sitting week of the Spring session of Parliament – “that the Senate pass the Bills”.

Committee Chair, Liberal Senator Slade Brockman, said that the Committee recognised that some people still had concerns about the policy categories, and the rules that will implement the product reforms.

“Some submitters disagreed with the inclusion of a Basic policy,” Senator Brockman said.

“CHOICE, the Australian Medical Association, the Australian Private Hospitals Association, and Day Hospitals Australia objected to the category on the basis that these policies provide low value cover to consumers, and exist to take advantage of the financial incentives provided by Government.

“Submitters also expressed concerns that, if the draft rules were adopted, particular products or services may only be available in high product tiers. For example … the AMA considered that, as 50 per cent of pregnancies are unplanned, pregnancy should be covered in Bronze rather than Gold.”

Senator Brockman said that the Committee understands that private health insurance can be a complex product that is confusing to many people.

AMA President, Dr Tony Bartone, appeared before the Committee in August, and told it that even doctors were confused by the array of choices and policies on offer.

“It is for that reason that we support the concept of developing Gold, Silver, and Bronze insurance categories,” Dr Bartone told the inquiry.

“Doctors are intelligent people. But I can tell you that we are all bewildered by the many different definitions, the carve-outs and exclusions from some 70,000 policy variations.

“That’s not my figure – it’s the Government’s. It’s unbelievable. No wonder we’re always being caught out.”

The Committee called for a public information campaign to help consumers understand the product design reforms, saying that would allow more consumers to be better informed about the different tiers and their inclusions.

Greens Senators Richard di Natale and Rachel Siewert lodged a dissenting report, arguing that the reforms would have little effect in improving the sustainability of the market.

“What we are instead seeing is an ideological commitment to throw good money after bad,” they said.

“The private health system operates only through the generosity of vast public subsidies of more than $6.5 billion each year. There is no argument that, without these subsidies, the market would collapse.”

Labor Senators Lisa Singh and Murray Watt also raised concerns that the reforms could have unintended consequences, including making it easier for insurers to cancel policies and harder for Australians to afford care when they need it.

“Labor Senators therefore support calls by the Australian Medical Association, Australian Healthcare and Hospitals Association, and others for the measures in this Bill to be reviewed after implementation,” they said.

They endorsed the main report’s recommendation to pass the Bills, ensuring their passage through the Senate.

The Government is expected to move to finalise the legislation in the Spring session.

The Committee report is available at https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/PrivateHealthInsur2018.