Bumper profits come at a heavy price

Medibank Private has headlined a year of bumper returns for private health insurers, announcing a 46 per cent surge in after-tax profits to reach $417.6 million, underlining concerns that the industry is pursuing financial returns at the expense of patients and service providers.

The latest snapshot of health fund finances shows that premium revenue across the industry surged by 6.4 per cent in the year to 30 June to reach $22 billion, far outstripping a 5.3 per cent increase in payouts ($19 billion), delivering insurers a healthy after-tax profit of $1.21 billion – up 8.8 per cent from the previous financial year.

The stunning results come amid widespread discontent about the behaviour of the health insurance, including large premium increases, complex and poorly explained health policies, arbitrary changes in coverage, routinely contesting and delaying payouts, and aggressive negotiation tactics with hospitals and other providers.

The Federal Government has announced changes to improve the value of health policies, including mandating minimum levels of cover and banning junk public hospital-only policies, and in his speech to the National Press Club AMA President Dr Michael Gannon lambasted the sector for prioritising profits over patients.

“Increasingly, we are seeing behaviour by large private health insurers that reflects that their ultimate accountability is to their shareholders,” Dr Gannon said. “If the actions of the funds continue unchecked and uncontested – especially their aggressive negotiations with hospitals and their attacks on the professionalism of doctors – we will inevitably see US-style managed care arrangements in place in Australia.”

While Medibank attributes much of its strong profit result to unexpectedly low claims, it has also been aggressively cutting costs and undertaking “claim control” initiatives.

Across the industry, insurers are looking to claim day on payouts, including by pushing more of the cost of treatment on to policyholders.

Patients faced a 6.9 per cent jump in out-of-pocket costs for hospital services last year, paying out on average $301.22.

Worryingly for Medibank and other insurers, there are signs that disenchanted policyholders are starting to vote with their wallets.

Medibank has reported a 2.6 per cent decline in customers, while premium revenue grew by just 5.1 per cent despite a Government-approved increase of 6.59 per cent, showing that many chose to downgrade their cover.

Industry-wide, the number of policies sold increased by just 0.57 per cent, less than half the rate of population growth, and the number insured grew only 0.46 per cent.

The industry’s struggles are only likely to intensify in coming months. Government measures to extend the freeze the threshold for the Medicare Levy Surcharge, $180,000 a year for families and $90,000 a year for singles, have come into effect. The thresholds will be frozen at current levels until 2021, when they will be roughly equivalent with average full-time incomes.

The Government is also planning to put a three-year freeze on the thresholds for the Private Health Insurance rebate before Parliament, which would see an increasing proportion of households kicked off the rebate.

Adding to Medibank’s woes, the consumer watchdog has taken the insurer to the Federal Court alleging it engaged in misleading and unconscionable conduct by cutting the benefits it would pay without informing policyholders.

Nonetheless, the industry is well placed financially. Total assets increased by almost a billion last financial year to reach $12.8 billion, and are growing at double the rate of liabilities, which were just $5.7 billion in 2015-16.

Adrian Rollins

Invest in health to avoid political disaster, Gannon tells Govt

The Federal Government must boost investment in general practice and public hospitals if it wants to avoid “a major Medicare headache” at the next election, AMA President Dr Michael Gannon has warned.

As the re-elected Turnbull Government finalises plans to put $6.5 billion of spending cuts, including in health, before the new Parliament, Dr Gannon has called for a change in the Coalition’s mindset away from seeing health as a cost and instead view it as an investment, warning that the Government’s political survival is at stake.

In his inaugural address to the National Press Club, the AMA President said the knife-edge result of the Federal election showed that Australians were “very comfortable with the state being in charge of their health and education” and did not like political parties messing with the system.

“There is no doubt that health was a game-changer in the election. It was very nearly a government-changer, too,” Dr Gannon said. “For many Australians, the health system – doctors, nurses, allied health, hospitals – is called Medicare. They see any threat to Medicare as bad.”

Prime Minister Malcolm Turnbull has acknowledged the political damage the Government inflicted on itself through its plans to introduce a co-payment for GP services and its cuts to public hospital funding, and has already had several meetings with Dr Gannon in an effort to try and improve his Government’s relationship with the medical profession.

But Dr Gannon said that, while the more consultative approach was welcome, it had to result in better policy, reiterating the AMA’s demands for an end to the Medicare rebate freeze, increased funding for public hospitals, the restoration of bulk billing incentives for pathology and diagnostic imaging tests and increased investment in preventive health.

The Government has so far shown no signs of budging on its decision to freeze Medicare rebates until 2020 as it tries to hold health expenditure down.

But Dr Gannon said the policy was a false economy because it was hurting GPs, who were providing the most cost-effective care in the health system. Furthermore, it would result in more patients deferring seeing their family doctor and eventually requiring much more expensive hospital care, and was undermining the goodwill of GPs, which would be needed for the successful implementation of the Health Care Homes initiative.

Just 6 per cent of the Government’s health spending goes on GP services, and Dr Gannon said general practice represented “very, very good value for money”.

But instead of getting support, GPs were being crushed in a “diabolical squeeze” as funding has been held down and cut even as demand for their services has continued to climb.

“GPs are now at breaking point,” the AMA President said. “Unless there is substantial investment in general practice, there is no doubt that the quality of care will start to suffer – and patients will face growing out of pocket costs.”

He warned that patients who are currently bulk billed may face out-of-pocket costs of $20 or more and “without a big re-think on the range of policies that affect general practice, the Government could have another major Medicare headache at the next election”.

Health Care Homes

One of the Government’s boldest reforms is to establish the Health Care Home model of care for patients with chronic illness. Under the plan GPs would, in addition to their current fee-for-service remuneration, be paid to help the chronically ill manage their disease.

Dr Gannon said it was “potentially one of the biggest reforms to Medicare in decades”, and the AMA was keen for it to succeed.

But he warned that it faced major obstacles without a change in approach by Government.

So far, the Government has only committed $21 million for a trial of the concept, none of which will go toward patient care.

Dr Gannon said that asking GP to provide enhanced care without any extra support “simply does not stack up”.

The Government also need to overcome the “significant trust and goodwill deficit” it had with general practitioners.

“Unless the Government restores some goodwill by unravelling the freeze and invests the extra funding that is required for enhanced patient services, GPs will not engage with the trial, and will walk away from this essential reform,” he said.

Prevention better than cure

Dr Gannon used his Press Club speech to intensify the pressure on the health insurance industry, accusing health funds of putting profits before patients and warning of a slide toward US-style managed care if they had their way.

The Government has acted on mounting discontent with the quality of health cover by announcing plans to ban ‘junk’ public hospital-only policies, mandating minimum levels of cover and introducing a simplified rating system for policies.

The AMA President said these were important steps, but the Commonwealth needed to provide much greater support for public hospitals.

In 2014, the Abbott Government controversially walked away from the previous Labor Government’s hospital funding agreement with the states, at a cost of $57 billion over 10 years.

Dr Gannon said public hospitals were “an everyday saviour for Australian families”, but were failing to meet waiting time and treatment targets as “a direct consequence of the Commonwealth’s failure to fund their share”.

He said the States and Territories did not have the revenue base to increase their funding, and the “Commonwealth Government needs to step up”.

To help contain this cost in the long term, Dr Gannon said the Government should lift its investment in preventive health.

He said health literacy levels were low, and every day people were making bad choices about what they ate, drink and did that would have consequences for their own health and for demand for health care.

“Preventive health is not about implementing a ‘nanny state’ or taking away people’s ‘choices’,” Dr Gannon said. “There are not enough public health campaigns and we continue to fund, at tremendous expense, the consequences of failures to prevent chronic health conditions.”

He said the success of action to curb smoking showed what could be achieved, and it was time alcohol was taken out of the ‘too hard’ basket.

In his speech, Dr Gannon also highlighted the urgency for action to improve Indigenous health. He expressed strong support for the Royal Commission into juvenile detention in the Northern Territory, and backed constitutional recognition as a way to “help heal some of the wounds that underlie Indigenous disadvantage”.

Adrian Rollins

New plan to find poor performing doctors

Screening for at-risk doctors and strengthening CPD are two key points highlighted in a new expert report released by the Medical Board of Australia.

The consultation and discussion paper were released on Wednesday, proposing a new approach to revalidation of doctors in Australia.

Board Chair, Dr Joanna Flynn AM said in a statement: “Regulation is about keeping the public safe and managing risk to patients. Part of this involves making sure that medical practitioners keep their skills and knowledge up to date.”

The proposal has two main parts.

Strengthened CPD – a ‘smarter not harder’ approach that will be evidence based to drive practice improvement and better patients outcomes.
Identify and assess at risk and poorly performing practitioners – an accurate and reliable way to screen practictioners at risk of poor performance will be developed. The report identifies that doctors more at risk include age (from 35 years, increasing into middle and older age), the male gender, number of previous complaints and time since last complaint. Other risk factors include getting qualification in some countries of origin, certain specialties, those who don’t respond to feedback, those who have an unrecognised cognitive impairment, doctors practising in isolated areas, doctors who do low levels of high-quality CPD activities and who have had a change in scope of practice.

According to Dr Flynn: “Most of the practitioners in the at-risk groups will be able to demonstrate that they are performing satisfactorily, just as most people who are screened in a public health intervention do not have the disease for which the screening program is testing.“

Those who have been found to be under-performing would then go through a ‘tiered, multi-faceted assessment strategy’ which would be scaled to match the perceived level of risk. There could be peer review and feedback processes or a more thorough evaluation for those considered to be seriously under performing.

Remediation would also depend on the nature and level of risk, although according to the report, “there is little information about long-term outcomes of remediation on doctors’ subsequent performance.” There will be continued research to confirm the efficacy of remediation interventions.

The Medical Board is now consulting about the proposed changes and want to hear from the medical profession about their thoughts.

“We want a system in Australia that is practical, effective and evidence-based, and we want to hear what the community and the medical profession think about the approaches proposed by the expert advisory group,” Dr Flynn said.

Options on the revalidation page include:

have your say in the online discussion
take a short survey to provide your views on the approach
send your written submission by email or mail
read submissions made by others

The consultation closes on 30 November 2016 and the final report is expected by mid 2017.

Latest news:

Remote Australians more likely to be hospitalised with heart-related issues

Patients from very remote Australia are nearly twice as likely to need a hospital for a heart-related event.

The Heart Foundation has released heart-related hospital admissions data maps, revealing huge gaps between city dwellers and those living in remote Australia.

Heart Foundation National Chief Executive Officer Adjunct Professor John Kelly said the maps bring together a national picture of hospital admission rates for the first time.

“Those regions that rate in the top hotspot areas are regions where a large proportion of residents are of significant disadvantage. This disadvantage includes a person’s access to education, employment, housing, transport, affordable healthy food and social support,” he said.

“This contrasts to areas with the lowest rates – particularly the northern suburbs of Sydney, where there is little disadvantage of the community.

“There is a five-fold difference of hospital admissions between Northern Territory Outback and the region with the lowest admission rates North Sydney & Hornsby, which highlights the association between remoteness, disadvantage and our heart health.”

The heart maps reinforce the knowledge that heart admissions are correlated with obesity, smoking and physical activity.

However Professor Kelly points out that the differences are not because people from disadvantaged areas make unhealthy choices.

“They are the result of a combination of social, economic and physical conditions, like a person’s access to education, employment, housing, transport, affordable healthy food, and social support,” he explained.

“These conditions shape matters such as people’s eating habits, participation in physical activity and their likelihood to see a doctor.

He said governments and health services need to work together to provide access and opportunities for people in more remote locations.

“Prevention programs work, simple early detection and heart health checks by doctors can help early identification of the risk factors and reduce hospital admissions.

“Health is a basic human right. It should not matter who you are, how much you earn or where you live,” he said.

Top 5 Regions for Heart-Related Hospital Admissions

Top 5 Regions with the lowest heart-related hospital admission rates

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Health Care Home success depends on GP goodwill

General practice is the corner stone of primary care. I am sure you will all agree with this. General practice in Australia has an exemplary record compared with many other countries around the world. It is efficient and extremely low cost, especially compared with an uncomplicated ED presentation.

The public, and the public purse, is extremely well served by general practice. The cost of MBS expenditure on general practice is just 6 per cent of total Government spending on health. Fee for service (FFS) has been the predominant funding model of general practice over that time.

The Government’s Health Care Home (HCH) is a model of care for patients with chronic disease. It is also known as the Medical Home. Under the model, patients have a continuing relationship with a particular GP to coordinate the care delivered by all members of the patient’s care team.

Do we need it? Especially when we consider the exceptional current performance and achievements of GP in Australia?

The significant twin burdens of burgeoning chronic disease and advancing age presentations are challenging the economic resources for delivering primary care. In an environment where fiscal resources are tight, the FFS model’s ability to cope with the pressure on the public purse is under the microscope.

Superimpose this on years of cuts to GPs – years of continued underfunding and non-investment by successive governments in general practice has brought GPs to the brink.

BEACH data shows that GPs are managing more chronic disease than ever before. GPs are already under substantial financial pressure due to the Medicare freeze and a range of other funding cuts. The HCH model is certainly not a way for the Government to arrange funding to general practice in the current Medicare rebate freeze environment.

The Medical Home is fundamental to the concept of the family doctor who can provide holistic and longitudinal care and, in leading the multidisciplinary care team, safeguard the appropriateness and continuity of care.

All this is academic if the funding for HCH is not appropriate, and not simply at the expense of FFS. Which brings us to the trial (or as the Health Department wishes to view it, as phase one of the implementation).

In March, the Government committed $21 million to allow about 65,000 Australians to participate in an initial two-year trial involving up to 200 medical practices from 1 July 2017. This funding is not for services, just for the infrastructure required to support the trial, as well as its evaluation.

The Health Department is busily preparing for this implementation. There is a hive of activity as it seeks to implement this key part of the Government’s strategy for reform. The overarching implementation advisory group will liaise to ensure that best practice and appropriate strategies are followed in the trial. AMA is on both the implementation group and underpinning subgroups involved in the mechanics of selecting patients and the economics of payment mechanisms.

The next few months will see many announcements, including the identification of the Primary Health Network (PHN) regions and an invitation for expressions of interest from practices in those regions to be part of the trials. The success of this policy initative will also depend on developments and further progress on the MyHealth Record and the PHNs (not without their challenges also).

The Department rightly understands that the goodwill of GPs is crucial for the success of the trial.

That goodwill will evaporate significantly if there is not the appropriate funding. However, I have made it clear that with additional funding support, GPs can provide more preventive care services and greater management and coordination of care. More important still, they can keep patients healthier and out of hospital, saving unnecessary and more expensive presentations and hospital admissions down the track – a measure which will form a key part of the evaluation of the success of the trial.

Making a difference

As a doctor, one of my key objectives is to improve my patients’ health, wellbeing and quality of life. I’m sure that you share this goal. Making a real difference in someone’s life is what gets me up every day. But how do I really know that I’m making the difference I think I am?

Often the results of my interventions are more immediate. I help a patient make an informed decision about an immunisation, or I clean and stitch a wound minimising the scar and risk of infection. I might have diagnosed a case of pneumonia and prescribed a course of treatment to relieve and eradicate my patient’s symptoms.

Other times it is less immediate. I might work with a patient to empower them to better manage their chronic disease, aiming to minimise its advance, the risks of associated multi-morbidities and its impact on their everyday life. This is much harder to measure and assess.

Aside from what I can see with my own eyes at an individual level, to confirm I am making a difference, the reality is that I need to record my actions, review the outcomes of my actions and evaluate this against my peers, or a best practice benchmark.

Understanding how I am performing can enable me to identify where I could do better and provide a personal benchmark from which I can follow a process of continuous improvement that will improve the efficiency of my practice and the quality of the health care I provide my patients.

While this can be challenging, it is very important to ensure my clinical practice is evolving in line with my peers, enhancing my effectiveness and helping me to deliver the health care my patients value.

Continuous quality improvement is often sold as a package of principles, methods and techniques that can be overwhelming and seemingly unsustainable for a busy GP. The best way to eat an elephant, I’ve been told, is one mouthful at a time. This is the approach I believe is required to implement a sustainable process of continuous quality improvement in general practice. But where to start?

The key to any objective evaluation is quality data. The key to quality data is standardised clinical terminology – in other words, coding. Before the end of this year it is expected that the two largest providers of clinical software will have enabled mapping of their coding systems to the SNOMED clinical terminology. This will be a huge enabler for many practices when extracting and analysing their data. They will be able to undertake simplified data extractions and compare apples with apples.

Accreditation and incentives such as those provided under the Practice Incentive Program, Quality Improvement and Continuing Professional Development requirements have been instrumental in facilitating GPs in improving their practices and processes, and in keeping their knowledge and skills up to date. But at the end of the day, the question that really matters is – did we make a difference.

The challenge is how to answer this question. Much of the answer is potentially at our finger tips or sitting in front of us, in our clinical data. For example, what percentage of our patients have their cholesterol levels recorded, what percentage have improved their levels in 12 months since a diagnosis of high cholesterol. How many have levels within the optimum range. Do our patients feel better, can they cope, can they move more freely, is their pain managed, did we listen to them, did we help them understand their condition and treatment options, did we follow up on them?

The discussion about quality improvement in general practice has started. The Health Care Home initiative will look at how practices can develop quality assurance processes, and it is important for general practice to do more to demonstrate to Government just how good our standards of care are. This is not about pay-for-performance but rather, how we ensure that GPs have the tools and information they need to better support a culture of continuous quality improvement.

Private insurers being brought to account

The AMA’s activities over several years to shed light on the egregious behaviour of certain private health insurers is now bearing fruit.

The Australian Competition and Consumer Commission (ACCC), the Commonwealth Ombudsman and the Federal Government are now taking action to curb unacceptable practices and shift the focus onto consumer needs, informed by AMA advice and submissions.

As part of its work in this area, the AMA recently made a submission to the Government’s review of private health insurance policy. Our submission called for the Government to abolish ‘junk’ policies; prevent insurers from arbitrarily introducing exclusions in policies and benefit payment schedules without prior advice; and prohibit insurers from encouraging consumers to purchase a product, or downgrade their cover to a level that is inappropriate to their health care needs.

In addition, the AMA’s inaugural AMA Private Health Insurance Report Card issued in February this year sent a clear message that consumers could not take at face value information provided by their health insurer. We warned consumers to avoid ‘junk policies’ – those that provide cover only for treatment in public hospitals – and to ensure they clearly understood the level of benefits paid by their insurer and likely out-of-pocket costs.

In response, the Government has now announced that it will eliminate junk policies as a part of its program of private health insurance reforms.

The Government also intends to create a three-tiered system of policies that will allow consumers to more easily choose a product that is right for them. It will mandate minimum levels of cover for policies, and develop standardised terminology for medical procedures.

These proposals will require detailed consideration to ensure an appropriate balance between private and public health care is maintained. This work will keep the Medical Practice Committee busy this year.

The Government has also responded to our complaints that the operations of third party comparator sites for private health insurance are not transparent; ‘comparisons of best value’ exclude some policies and commissions are kept secret. The Government will require third party comparator sites to publish commissions they receive, similar to the requirements for other financial services.

The Commonwealth Ombudsman is also investigating those insurers who are insisting on seeking ‘pre-approvals’ for plastic and reconstructive procedures. Many of our surgeon members have been affected by this practice in which insurers require private hospitals to get surgeons to fill in and ‘certify’ a form providing clinical details of the procedure and the reasons why it is necessary.

While insurers continue to claim that this process is not compulsory and does not constitute a ‘preapproval’, we understand that patients, hospitals and medical practitioners are being told that if forms are not submitted, benefits will not be paid.

In direct response to AMA concerns, the Department of Health wrote to all insurers in 2015 reminding them that, under law, they must pay benefits for a hospital treatment when an insured member undergoes a procedure for which a Medicare benefit is payable, and which is covered by their health insurance product.

Clearly this advice has been ignored, but the Ombudsman’s investigation will hopefully put a stop to this practice.

Finally, the ACCC is taking legal action against Medibank Private for allegedly misleading consumers – specifically, failing to give notice to members on its decision to limit benefits paid for in-hospital pathology and radiology services.

As mentioned earlier, we raised the issue of arbitrary changes to policies and benefits in our submission to the Government’s private health insurance review last year, but we also brought this to the attention of the ACCC in our 2016 submission concerning insurer activities designed to erode the value of private health insurance cover and maximise insurer profits.

Commenting on its legal action, the ACCC said: “Consumers are entitled to expect that they will be informed in advance of important changes to their private health insurance cover, as these changes can have significant financial consequences”.

The AMA wholeheartedly agrees.

Govt must wise up after bruising election result

After a substantial delay, we now have a Government, and both major parties are in soul-searching mode.

What was clear from the election campaign was the significant focus on health. Prime Minister Malcolm Turnbull indicated that the so-called ‘scare campaign’ on the privatisation of Medicare had had some effect, and the Coalition needed to do more to reassure the electorate that his Government was committed to health, hospitals and Medicare funding.

This is all highly noble in hindsight, but it is clear the Government had left the door wide open for the scare campaign, with several health-related faux-pas leading up to the election, including the proposal for co-payments, and some of its lingering health policies. Australians value their health, but particularly the work of public hospital doctors. A scare campaign does little to instil confidence in a system buckling under the pressure of enormous budget cuts and ongoing high expectations for service delivery.

You will remember that there were two models of co-payment, and both of them were roundly rejected by the AMA. Neither model accounted for the neediest in our community, who frequent our public hospitals. Evidence suggests that some people, when faced with even nominal costs, will defer necessary visits to the doctor, and even potentially life-saving procedures or investigations such as blood tests, x-rays or ultrasounds. This just compounds problems down the track, with patients more likely to face emergency presentations.

We understand the Government’s desire to constrain health spending, but sustained health care available to all Australians is the most economical model in the long run. We don’t want to emulate highly-paid CEOs and their short-term financial goals. Whatever model we develop, we must account for those in the community whose access to health care is constrained by factors such as location and/or social and economic circumstances.

The AMA needs to be part of an open, responsible debate about funding the national health system. There are elements of the health system that the Commonwealth pays for directly, but State Governments are struggling to fund the increasing demands on health and public hospitals, leading to the budget cuts we know too well.

It should not be forgotten that our health system represents great value for money by world standards, particularly in certain areas, but our public hospitals are now overtly overworked and underfunded. They are truly an investment in the health of our nation, our economic productivity and our future. Minister Ley must continue to make these arguments at the highest levels of Cabinet.

Having admitted that health worked against it in the election, the Government must now “wise up” and set a new health policy direction. Alongside issues such as the Medicare rebate freeze, the Government must, from the public hospital doctors’ perspective, properly fund public hospitals and make a renewed commitment to investing in preventive health measures.

Most importantly, the Government must consult closely with the profession in the development of health policies to ensure better outcomes. They must recognise that the medical profession is best placed to advise on health policy.

I look forward to engaging with you through the Council of Public Hospital Doctors as we advocate on these and other important issues and brace for the journey ahead.

Govt investment in doctors of the future still falling short

As the new Chair of the Medical Workforce Committee (MWC), I am looking forward to harnessing the committee to drive the AMA’s response to the medical workforce crisis.

I would like to acknowledge Dr Stephen Parnis for his stewardship of the MWC as inaugural Chair. Like Stephen, I have a long-standing interest in medical workforce issues, and believe that ensuring Australia has the medical workforce to meet community needs is a critical challenge for governments and health policymakers.

Over the last 15 years the number of medical school places has increased substantially in response to past workforce shortages. But the need for more medical schools is over, as we know from successive sets of workforce data that Australia now has sufficient numbers of medical students. We must now focus on improving the distribution of the medical workforce, and providing enough postgraduate medical training places, particularly in rural and remote areas and the under-supplied specialty areas.

At the recent Federal Election, the AMA offered four important policy proposals to help achieve this outcome:

expanding the National Medical Training Advisory Network’s (NMTAN) workforce modelling program;
establishing a Community Residency Program;
increasing the GP training program intake; and
expanding the Specialist Training Program.

NMTAN is the Commonwealth’s main medical workforce training advisory body, and focuses on planning and coordination. It has representatives from the main stakeholder groups in medical education, training and employment.

NMTAN’s report on the psychiatry workforce was released in March. This is the first specialty report to be finalised by NMTAN since Health Workforce Australia was axed in 2014. It contains valuable data and analysis, including a projected undersupply of 125 practitioners by 2030 for the psychiatry workforce, despite a likely increase in the number of Australian-trained psychiatrists.

NMTAN is intending to beef up its work program. The AMA has argued consistently for complete workforce modelling and reporting across all medical specialties by the end of 2018; it is vital to have data sooner rather than later on imbalances across the specialties to enable effective workforce planning.

We will continue to engage with the Government of this issue. In the meantime, we await with interest the expected release of the reports on the anaesthesia and general practice workforces later this year.

An important piece of work undertaken by the MWC last year was developing the Community Residency Program for Junior Medical Officers (CRP). This is the AMA’s proposal to establish and fund a program for high-quality prevocational placements in general practice for junior doctors as a replacement for the valuable Prevocational General Practice Placements Program abolished by the Government in 2014.

We continue to lobby for our CRP. The Government’s announcement late last year that it will fund 240 rotations in general practice settings for rural-based interns is a partial replacement for the PGPPP, and was an admission by the Government that its decision to abolish the program was a backward step, especially for rural health.

As a practising GP, I am keenly aware that more resources are needed to build and maintain a sustainable GP workforce.

The AMA’s call to increase the GP training program intake to 1700 places a year by 2018 is worthy of the Government’s consideration. This must be backed with solid measures to support GP training, including incentives for supervisors and investment in training infrastructure. Rural general practices need grants to help them expand their facilities and provide more teaching opportunities for medicals students and GP registrars, and to enhance the range of services they provide.

The Commonwealth’s Specialist Training Program (STP) is a valuable workforce program that is giving specialist trainees the opportunity to train in settings outside traditional metropolitan teaching hospitals. Though the Government has committed to provide 1000 placements by 2018, the AMA strongly believes that the STP must be expanded to 1400 places a year, with the focus on encouraging specialist training in rural settings and specialties that are under-supplied.

Other areas of focus for the MWC will be promoting generalism in the medical workforce, encouraging greater gender diversity in medical leadership, and increasing clinical supervision capacity.

Progress, but much more to do.

AMA calls for independent scrutiny of asylum seeker health

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Disturbing accounts of sexual assault, neglect and harm among asylum seekers being held at the Nauru detention centre reinforce the need for oversight by an independent statutory body of clinical experts, AMA President Dr Michael Gannon has said.

Leaked details of more than 2000 incident reports from staff at the Nauru Regional Processing Centre, published by Guardian Australia, reveal a litany of abuse, self-harm, sexual assault, inadequate health care and deplorable living conditions at the centre. The details come less than a week after a joint Amnesty International-Human Rights Watch investigation resulted in a scathing assessment of conditions at the centre.

Dr Gannon said the “disturbing” revelations, particularly regarding the treatment of children, leant fresh urgency to long-standing AMA calls for much greater scrutiny of detention centre operations and the provision of health services to asylum seekers.

“These disturbing reports echo long-held concerns by the AMA about the lack of proper physical and mental health care being provided to people in immigration detention,” Dr Gannon said. “The reports detail high levels of trauma and mental illness, especially in children being detained on Nauru.”

The AMA regularly received reports from asylum seekers and their advocates – from within and outside the medical profession – detailing failures to provide proper physical and mental health treatment and services for asylum seekers, he said, and called for children to be removed from detention and placed into care in the community.

Conditions at the Nauru detention centre have been condemned by Amnesty International and Human Rights Watch, who have accused the Federal Government of a deliberate policy of “appalling abuse and deliberate neglect” in its treatment of refugees and asylum seekers being held there.

In their report, based on interviews with 84 refugees and asylum seekers as well as an unspecified number of service providers, the non-government organisations described medical facilities on Nauru as rudimentary and said those with serious conditions frequently faced long delays before receiving specialist care.

In one account, a service provider said ambulances sometimes took up to three hours to respond to calls from the centre, and often people were discharged from the local hospital while they were still sick or half-conscious.

“We are not allowed to ask the hospital why they are being discharged, or what medication they’ve been prescribed, or for their medical records,” the service provider said.

Among the 2116 incident reports from detention centre guards, caseworkers and teachers leaked to Guardian Australia are numerous accounts of children threatening to kill themselves, engaging in highly sexualised behaviour, or suffering great emotional distress.

In one account, a group of security guards was heard to laugh moments after one of them was called to a young girl who had sewn her lips together. In another, a teacher reported that a student was “dreaming of blood and death and zombies” because his mother was on hunger strike and refused to hug him. Several reports detailed children sitting on the laps of security guards, including one girl who was “leaning her backside into the crotch of [name redacted]”, and a boy who was being bounced on the lap of a guard who was whispering in his ear.

Amnesty International and Human Rights Watch representatives who visited the island for 12 days last month said the circumstances in which people were being detained – a third of the 1200 refugees were living in cramped tents in hot and humid conditions, and all were limited to two-minute showers and forced to use filthy toilets – were physically draining and exacerbated mental health problems.

“Prolonged detention in appalling conditions exacerbated the trauma many had suffered from persecution in their home countries,” the report said.

Many of those interviewed reported having developed severe anxiety, insomnia, mood swings, prolonged depression and short-term memory loss while on the island, while children were suffering from nightmares and engaging in disruptive and troubling behaviour.

“Adults and children spoke openly of having wanted to end their lives. More than a dozen of the adults interviewed said they had tried to kill themselves…and many more said that they had seriously considered ending their lives,” the report said.

It included the account of a nine-year-old boy who told his mother that, “I want to burn myself. Why should I be alive? I want my daddy. I miss my daddy”, after his father was transferred to Australia, without his family, for medical treatment.

Amnesty International and Human Rights Watch said support and treatment for those suffering mental health problems was inadequate, and patients whose illness was severe enough to justify their transfer to Australia were returned several months later to the same conditions that had contributed to their trauma in the first place.

Dr Gannon said such treatment was unacceptable.

“The AMA’s position is clear – people who are seeking, or who have been granted, asylum within Australia have the right to receive appropriate medical care without discrimination, regardless of citizenship, visa status, or ability to pay,” Dr Gannon said. “Asylum seekers and refugees under the protection of the Australian Government should be treated with compassion, respect, and dignity.”

The AMA has reiterated its call for the creation of a national statutory body of clinical experts, independent of Government, with the power to investigate and report to the Parliament on the health and welfare of asylum seekers and refugees in Australia and in offshore detention.

“Australia’s atrocious treatment of the refugees on Nauru over the past three years has taken an enormous toll on their wellbeing,” Human Rights Watch Senior Counsel on Children’s Rights Michael Bochenek said. “Driving adult, and even child, refugees to the breaking point with sustained abuse appears to be one of Australia’s aims on Nauru.”

Amnesty International Senior Director of Research Anna Neistat, who was one of the researchers who visited Nauru, condemned the treatment of asylum seekers as “cruel in the extreme”.

The human rights organisations said the Australian Government’s failure to address what they described as serious abuses “appears to be a deliberate policy to deter further asylum seekers from arriving in the country by boat”.

But the Department of Immigration and Border Protection rejected the findings of the Amnesty report, which it said was conducted without consultation.

“We strongly refute many of the allegations in the report, and would encourage Amnesty International to contact the Department before airing allegations of this kind,” it said in a statement.

The Department said Australia did not “exert control” over the Nauruan Government, though it did fund accommodation and support services for “all transferees and refugees, including welfare and health services”.

“We welcome independent scrutiny of regional processing matters, noting that access to the [Regional Processing] Centre is a matter for the Government of Nauru.”

But the Government’s has been accused of trying to hide its treatment of asylum seekers behind a shroud of secrecy.

The Australian Border Force Act, passed last year, threatens up to two years imprisonment for detention centre staff and contractors who publicly disclose information about operations.

But Dr Gannon said doctors should be able to speak out without fear of retribution or prosecution, and the legality of the Act is being challenged in the High Court by the group Doctors for Refugees.

The AMA Federal Council is also looking into claims former medical director of mental health services for detention centre contractor International Health and Medical Services, Dr Peter Yong, was subject to surveillance by the Australian Federal Police.

Adrian Rollins