Pathology rent cap will cost patients, doctors

The AMA has warned that Federal Government proposals to cap pathology collection centre rents will likely drive up patient out-of-pocket costs and could force some medical practices out of business.

In a strongly worded letter, AMA President Dr Michael Gannon has appealed to the Small Business and Family Enterprise Ombudsman, Kate Carnell, to intervene and help try to convince the Government to drop its plan.

Dr Gannon said the proposal, announced during the Federal election, to change provisions in the Health Insurance Act would allow the two major pathology companies that dominate the market to unilaterally cut the rents they paid to medical practices for co-located collection centres (ACCs), delivering a big financial blow to small business already reeling under the effects of the Medicare rebate freeze.

“The proposed changes fundamentally alter the intent of the existing law…by imposing a blunt cap on the commercial rents that GPs and other specialists can receive for co-located ACCs,” the AMA President said. “It delivers two major listed companies with an unwarranted and unfair advantage…estimated to save [them] between $100 million and $150 million per annum.”

Under the deal, which was sprung on the medical profession without warning, the Government has promised to bring down rents in exchange for a promise from pathology companies that they will sustain bulk billing rates despite the loss of the bulk billing incentive.

Dr Gannon warned that the Government’s proposed changes would have “a big impact” on medical practices.

“Medical practices are [already] feeling the impact of the current MBS indexation freeze, and policy changes like this will simply have a further negative impact on their cash flow and on practice viability,” he said. “For those practices that have used this source of rental income to help keep them viable during the current extended freeze, it may it may mean higher costs to patients or simply selling their business.”

Many, the AMA President said, had made decisions about hiring staff and purchasing equipment based on anticipated revenue streams from ACC rents, and the policy would put their finances under strain.

Dr Gannon said it was unlikely the Government comprehended the full impact of the “poorly targeted” policy when announcing it, including the massive windfall it would deliver to the big pathology providers and the hefty financial blow it would deliver to many medical practices.

Adrian Rollins

Australians shedding their hard drinking image

Drinks sales are forecast to decline as growing numbers of Australians cut back on their consumption or quit altogether, in a sign that higher excises and lock-out laws are helping to curb the nation’s drinking problem.

Industry analyst IBISWorld expects per capita alcohol consumption, which has already dropped to a 50-year low, will continue to decline until at least the middle of the next decade as people heed health messages and respond to higher prices, drink-driving laws and other measures by reducing their intake.

The analyst predicts that by 2024 consumption will drop to 8.54 litres per person, a fall of almost 20 per cent from the start of this decade.

“We’re seeing increasing health consciousness among the under 30s, while at the other end of the market people are also drinking less,” IBISWorld senior analyst Andrew Ledovshkik told The Australian Financial Review.

The analysis echoes the findings of an Australian Institute of Health and Welfare report showing that consumption is declining, with 22 per cent reporting they had abstained from drinking in 2013 (up from 17 per cent in 2004), and the proportion who have never had a full drink reaching 14 per cent.

Even rates of risky drinking are declining.

The AIHW reported an 11 per cent drop in the rate of Australians drinking at risky levels on a single occasion (from 2950 to 2640 per 10,000 people), and 13 per cent drop who indulge in risky drinking over a lifetime, from 2080 to 1820 per 10,000.

The declines have paralleled changes to the cost and availability of alcohol.

The excise on beer and spirits is indexed twice a year and for some beverages has reached $81.21 per litre of alcohol. Wine is treated differently and is subject to a so-called equalisation tax currently set at 29 per cent of its wholesale value. Public health advocates are critical of the arrangement and argue that alcohol should be taxed at a minimum unit price that applies regardless of the beverage.

Several State governments, most notably New South Wales and Queensland, have also acted to restrict outlet trading hours and impose lock-outs in response to alcohol-fuelled assaults and murders.

The Institute said the results suggested that strategies including increasing the price of alcohol, restricting trading hours and reducing the density of outlets “can have positive outcomes in reducing the overall consumption levels of alcohol”.

Aside from making alcohol more expensive and difficult to get, there are signs that younger people are less inclined to drink to the same extent as older generations.

In the United States, a survey of 67,000 youths and adults conducted by the Abuse and Mental Health Services Administration found that just 9.6 per cent of adolescents aged between 12 and 17 years reported drinking alcohol in 2015, down from 17.6 per cent in 2002.

The question is whether others drugs are being used as a substitute for alcohol.

In the US, there has been a slight drop in heroin use, but prescription drug use and abuse is high. It is estimated that about 19 million Americans aged 12 years or older misused prescription drugs, mainly painkillers, in the previous year.

In Australia, about 3.3 per cent of those 14 years or older have used analgesics for non-medical purposes in the previous 12 months, 10 per cent have used cannabis, 2.1 per cent have used cocaine and methamphetamine, 2.5 per cent have used ecstasy, 1.3 per cent have used hallucinogens and 0.1 per cent have used heroin.

But even with the decline in its consumption, alcohol remains a major health problem. It was the leading cause of disease burden for the under 45s in 2011, and alcohol use disorders accounted for 1.5 per cent of the total burden of disease that year.

Adrian Rollins

Sexual transmission of HIV and the law: an Australian medical consensus statement

All Australian states and territories have criminal laws that may be applied in cases of alleged human immunodeficiency virus transmission and, in some jurisdictions, exposure. None of these laws are HIV specific; they generally relate to causing grievous bodily harm, serious injury or grievous bodily disease, or to endangerment by exposure to the risk of infection.1

There have been at least 38 Australian criminal prosecutions for HIV sexual transmission or exposure since the first known case in 1991. Such cases require that courts, legal practitioners and juries interpret detailed scientific evidence on HIV transmission risk and the medical impact of an HIV diagnosis. Analysis suggests that scientific concepts have been inconsistently applied in Australian trials involving HIV.1,2 In some cases, the risks and impacts of HIV infection may have been overstated.

It is not the intention of this consensus statement to directly critique the evidence in past trials, or to suggest that any miscarriage of justice has occurred. Rather, we hope to inform the criminal justice system to ensure that future allegations are addressed in a scientifically robust way, consistent with the interests of justice. This statement, which draws on a similar consensus statement published in Canada,3 represents our opinion based on a review of the best available medical and scientific evidence. The evidence demonstrates that most sexual encounters entail low to no possibility of HIV transmission. While HIV remains a serious infection, the medical impact of an HIV diagnosis has decreased due to improved treatment; most people recently infected with HIV are able to commence simple treatment that offers them a life expectancy comparable with that of their HIV-negative peers.

HIV transmission risk

HIV is not transmitted readily from one person to another. HIV cannot survive outside the body or be transmitted through air. For transmission to occur, particular bodily fluids from an HIV-positive person (blood, semen, pre-seminal fluid, rectal fluids, vaginal fluids or breastmilk) must enter an HIV-negative person’s body.

For HIV transmission to occur through sex:

There must be a sufficient amount of the virus in the HIV-positive person’s bodily fluid.
Bodily fluid containing HIV must come into contact with an HIV-negative mucous membrane or damaged tissue. Mucous membranes are located in the foreskin and urethra of the penis; cervix and vagina; anus and rectum; and mouth and throat. In the absence of trauma, oral mucous membranes are much less vulnerable to HIV transmission than anogenital mucous membranes.
The virus must overcome the cellular defences of the HIV-negative person’s mucous membrane and the body’s immune response to pathogens in order to establish an infection in target immune cells.

Assessing HIV transmission risk from sexual activity

HIV transmission during sex is not inevitable. In fact, HIV is more difficult to transmit via sexual acts than many other sexually transmitted infections (STIs). Unlike the risk of transmission through HIV-infected blood, which rises to almost 100% through blood transfusion,4 risk of transmission through sexual acts is relatively low.

This consensus statement uses three categories to define the possibility of HIV transmission per sexual act: low, negligible and none (Box). These categories have been developed to inform consideration of HIV transmission risk in a criminal justice context. They have been deliberately chosen to differ from terms used in the public health context (which usually describes activities as ranging from high to low risk), where the messages function to encourage safe sexual practice. This consensus statement is intended for a legal context and is a more precise reflection of our clinical understanding of the likelihood of HIV transmission per event.

The possibility of HIV transmission during sex varies according to a number of intersecting factors.

The amount of HIV in a person’s bodily fluid (viral load)

Soon after being infected, a person’s viral load is high. Then, as the immune system responds, viral load typically decreases. If a person does not commence treatment, their viral load will eventually increase until HIV overwhelms their immune system and they begin to develop HIV-related illnesses.

When treatment is commenced, the viral load usually drops to undetectable levels (less than 50 copies per millilitre of blood) within a few weeks (“undetectable viral load” or “effective treatment”). With continuing adherence to treatment, undetectable viral load is usually maintained for prolonged periods. Having an undetectable viral load dramatically reduces the risk of transmitting HIV.5,6

Some people may be unable to access treatment, choose to defer commencing treatment or be unable to achieve an undetectable viral load on treatment; however, even a low viral load reduces transmission risk.

Type of sexual activity

Some activities carry higher risk than others (see below).

Condom use

HIV cannot pass through intact latex or polyurethane condoms. HIV transmission is possible only where condom slippage or breakage occurs. Epidemiological evidence on the reliability of condoms shows using condoms reduces transmission risk by at least 80%,7 although recent research suggests that estimate may underestimate condom reliability.8 Importantly, condom-related risk operates in conjunction with the established risk of particular behaviours, so correct condom use reduces the risk of HIV transmission to a level that is almost unquantifiable.9

At a population level, studies have shown that even when factoring in possible instances of incorrect use or breakage, consistent condom use dramatically reduces the possibility of HIV transmission.7

Whether the HIV-negative partner is using effective pre-exposure prophylaxis (PrEP)

PrEP is the use of anti-HIV medication by HIV-negative people to prevent HIV infection. Correct use of PrEP by an HIV-negative individual substantially reduces the risk of HIV acquisition.10–12

Whether a person who believes they have recently been exposed to HIV takes post-exposure prophylaxis (PEP)

PEP describes commencement of short term antiretroviral treatment by an HIV-negative person within 72 hours of a risk event. Even when the virus has entered a person’s body, PEP can stop the virus becoming established, significantly reducing the likelihood of the person becoming HIV-positive.

Risk associated with specific sex acts

Oral sex including oral–penile sex (fellatio) and oral–vaginal sex (cunnilingus)

When an HIV-positive partner has a very low or undetectable viral load, or a condom or similar latex barrier is properly used, or the HIV-negative partner is taking effective PrEP, or where oral sex is performed by an HIV-positive person on an HIV-negative person, there is no possibility of HIV transmission from oral intercourse.13

When oral sex is performed by an HIV-negative individual on an HIV-positive individual with a detectable viral load, there is negligible possibility of HIV transmission.13 Risk of transmission increases if the HIV-negative partner has cuts or lesions in their mouth and the HIV-positive partner ejaculates, but the risk remains very low.

Vaginal–penile intercourse

When a condom is used correctly, or the HIV-positive partner has a very low or undetectable viral load, or the HIV-negative partner is taking effective PrEP, there is negligible possibility of transmission from vaginal–penile intercourse.5,14 When two or more of these prevention strategies are simultaneously employed, risk of transmission approaches zero.

When the HIV-positive partner has a detectable viral load and a condom is not used, there is a low possibility of transmitting HIV during vaginal–penile intercourse.15 If no ejaculation occurs inside the HIV-negative partner’s body, transmission risk decreases significantly.

Anal–penile intercourse

When a condom is used correctly, or the HIV-positive partner has a very low or undetectable viral load, or the HIV-negative partner is taking effective PrEP, there is a negligible possibility of transmission through anal–penile intercourse.16 Where two or more of these prevention strategies are simultaneously employed, risk of transmission approaches zero.

When a condom is not used, and the HIV-positive partner has a detectable viral load, anal–penile intercourse poses a low possibility of transmitting HIV.17 The risk is similar whether the receptive partner is male or female. The risk is lower where the HIV-positive partner takes the receptive, rather than insertive, role. The possibility of HIV transmission during anal intercourse decreases when no ejaculation occurs inside the body.

Other risk factors

Presence of an STI, particularly an ulcerative STI, in either partner has been associated with an increased risk of HIV transmission during sexual activity.18 However, the presence of an STI does not increase transmission risk if a condom is used correctly or the HIV-positive person is on effective anti-retroviral therapy or the HIV-negative person is taking PrEP.

Biting and spitting

There is no possibility of HIV transmission from contact with the saliva of an HIV-positive person through spitting or biting. There is a negligible possibility of HIV transmission from spitting or biting where the HIV-positive person’s saliva contains blood, and their blood comes in direct contact with a mucous membrane or open wound, and they have a high viral load. No transmission through biting or spitting has ever been documented in Australia.

Evidence of transmission: phylogenetic analysis as forensic evidence

A small number of Australian trials have admitted expert evidence based on phylogenetic analysis to show an accused caused the complainant’s HIV infection.19 While phylogenetic studies are invaluable as research tools, their probative value as evidence of causation is limited because of the limitations of the methodology. This statement aims to minimise the incorrect application or interpretation of phylogenetic analysis to prove causation in HIV transmission cases.

HIV’s genetic sequence is widely variable at a population level, and changes rapidly over time both in response to the host immune response and in cases of HIV treatment resistance. Consequently, comparisons of genetic sequences of samples of the virus taken from different individuals can estimate the likelihood that these samples are linked by transmission events.20 To test whether any relationship exists, phylogenetic analyses use a statistical approach to assess the relatedness of viral genetic sequences in a process analogous to, but significantly less specific than, DNA profiling. Samples of viral RNA from the complainant and accused (reference samples) are compared to determine the degree of similarity. A database of samples from randomly selected but unrelated individuals (control samples) is employed to estimate the probability of the reference samples being related through a common ancestor.

This assessment is influenced by the number of control samples, which has typically been small in the context of criminal cases.21 The small number of controls significantly limits the reliability of analysis.

Phylogenetic analysis has its most useful application in definitively ruling out a connection between the infections of the complainant and accused, but it cannot determine beyond reasonable doubt that the reference samples are linked. Even where there is a strong correlation (high similarity) between the RNA sequences (irrespective of the size and characteristics of the control group), alternative hypotheses must be discounted, including infection of the accused by the complainant, infection of both complainant and accused by a common source person, or infection of the complainant by a third person infected by the accused.

Understanding the harms of HIV infection

Over the past two decades, HIV antiretroviral drug regimens have become simpler, more tolerable, and much more effective.22–24 Consequently, HIV is now treated as a chronic illness. For many people diagnosed with HIV, effective treatment is achieved by taking a single pill each day. Most people on treatment are able to achieve an undetectable HIV viral load and maintain a healthy immune system, which makes it highly likely that the person will remain healthy for a very long time and ensures they pose a negligible risk of transmitting HIV to sexual partners.

Life expectancy after HIV diagnosis has dramatically increased,24,25 to the point that the life expectancy of a recently diagnosed adult on antiretroviral treatment approaches that of an adult in the general population.22 Given that individuals living with HIV often exhibit demographic, clinical and behavioural characteristics associated with greater morbidity and mortality than the general population,26 any remaining gap in life expectancy may be attributable to these factors.27

Treatment of HIV has improved to the point that HIV-related illnesses are uncommon among diagnosed individuals. Instead, the focus of HIV care has shifted towards the management of non-HIV-related chronic diseases (such as smoking-related cardiovascular disease) which may be exacerbated by HIV and/or its treatment. Australian HIV surveillance programs no longer record the number of deaths from AIDS (acquired immunodeficiency syndrome), as this is no longer considered a useful marker of Australia’s HIV epidemic.28

A better understanding of treatments and prevention has also revolutionised conception and childbirth where one or both partners is or are HIV-positive. Where a couple is hoping to conceive, specific interventions (including antiretroviral treatment and PrEP) allow them to conceive through vaginal sex with negligible risk of HIV transmission from one partner to another.29 HIV per se does not adversely affect pregnancy. If interventions are implemented to minimise HIV transmission risk from mother to child during pregnancy, birth and postnatally, and a woman’s viral load is less than 50 copies per millilitre of blood, HIV transmission risk is reduced to less than 0.09%, including through vaginal birth.30

Although arguably fear surrounding HIV has decreased as public awareness has improved, people with HIV may experience psychosocial disadvantage such as stigma, discrimination and difficulties in interpersonal relationships.31 Such experiences vary by individual, typically decrease over time, and may be responsive to psychological and counselling interventions.32 Unfortunately, media coverage of criminal trials appears to heighten stigma and exacerbate other psychosocial issues for people living with HIV.

Recommendations

Given the limited per act likelihood of HIV transmission during sex and the limited medical harms experienced by most people recently diagnosed with HIV, we recommend that caution be exercised when considering criminal prosecutions, with careful appraisal of current scientific evidence on HIV risk and harms.

HIV science continues to deliver impressive results. During the past decade, a fuller understanding of the effectiveness of HIV antiretroviral treatments as a preventive tool (including treatment of an HIV-infected person, and use of PrEP and PEP) has resulted in a significant decrease in estimates of HIV transmission risk during sexual acts. Similarly, research shows that improved treatments have delivered consistent increases in life expectancy. Given the rapid pace at which science is evolving, reference to risk and harms associated with HIV must reference the most robust and up-to-date evidence.

It has long been recognised that correct use of condoms is an effective means of reducing HIV sexual transmission risk to an acceptably low level. We now know that if an HIV-positive partner is on treatment and maintains an undetectable viral load, or if the HIV-negative partner takes PrEP correctly, risk is reduced to a similar degree. In our opinion, the use of any one of these strategies reduces the risk of transmission to a negligible level and represents taking reasonable precautions to prevent HIV transmission.

In clinical practice, it is extremely unusual to encounter a person who is dismissive of the need to protect others from HIV infection. In the rare instances where this does occur, public health management processes have proven very effective. Public health management guidelines in each state and territory focus on achieving sustained behaviour change through counselling, education and addressing the underlying causes of risk behaviour. Public health officials are well resourced to provide as much support, direction or restriction as required to prevent individuals putting others at risk of HIV infection, including isolation from the community in extreme circumstances.33

Given the effectiveness and lower cost of the public health management approach, and the relatively low per act risk of HIV transmission during sex, we recommend that prosecutorial authorities give consideration to public health management as an alternative to prosecution wherever appropriate.

Box –
Possibility of HIV transmission

Possibility

Conditions for viral transmission present

Reports of transmission (worldwide)

Possibility of transmission per act

Risk of transmission per event

Low

Usually

Most reports linked to these activities

Possible but risk remains low

1.4% (1/70) to 0.04% (1/2500)

Negligible

Very rarely

Isolated reports, difficult to confirm

Highly unlikely, if not impossible in most circumstances

< 0.016% (1/6250) to < 0.0016% (1/62 500)

None

Never

None reported

Not possible

Too low to quantify

Introducing an accessible series on statistics for clinicians

For many clinicians, statistics is the equivalent of a foreign language: they may know a few words here and there from their travels, but they have never had the time to learn the language properly. As health care providers, we are increasingly being asked to engage in critical appraisal and sort through the large volume of research to help guide decision making. For many, this means reading mainly the abstract and the discussion, and glossing over the jargon in the methods and results. This is unfortunate, as the methods can obviously make or break the validity of the results and determine whether we decide that a study is valid and practice changing, or fatally flawed and pointless.

This is not a novel endeavour. The whole evidence-based medicine movement began with the Users’ guide to the medical literature series originally published in JAMA in the early 1990s and now compiled in a book.1 These articles focused mainly on study design and introduced a whole generation of practitioners to clinical epidemiology. However, with the rise of desktop statistical packages, such as SPSS, STATA and SAS, complex statistical methods have been put within the reach of many investigators. The results have generally been positive in that complex analyses can be performed by many more people, but the room for error has also increased tremendously. Therefore, the need for caution and critical appraisal is even more urgent. Many series on basic statistics for clinicians have been published — such as a primer for clinicians in the Canadian Medical Association Journal2 and the ongoing statistics notes in The BMJ3 — but we have decided to take a fresh look at this topic with the purpose of providing a concise and accessible overview of commonly used statistical tests. The series will cover a number of statistical ideas and methods commonly used in medical studies and will be published at regular intervals. It will build over successive articles, so it might be useful to read them in order (at least initially). We have chosen not to cover some topics that have already been comprehensively discussed in the literature (eg, randomised controlled trials), and to cover others that may be less familiar (eg, receiver-operator characteristic curves). Our hope is that, by the end of this series, you will have grown in practical knowledge and will be reading the methods and results of research articles and feel empowered to come to your own conclusion about the wheat and the chaff in medical literature. We welcome suggestions from readers or contributions from other authors that will help to expand the series.

[Correspondence] Sodium and cardiovascular disease – Authors’ reply

Nicholas Wald and Malcolm Law, and Pasquale Strazzullo and colleagues propose that the association between sodium intake and blood pressure should parallel its association with cardiovascular disease events. Their reductionist assumption is that all lowering of blood pressure will translate into reductions in cardiovascular disease, irrespective of baseline measurement of blood pressure. This assumption is not supported by the HOPE-3 trial1 and a recent systematic review of 49 trials,2 which show a benefit of lowering systolic blood pressure when it is above 140 mm Hg at baseline, but adverse effects using the same intervention when baseline was below 140 mm Hg.

[Correspondence] Sodium and cardiovascular disease

The Article by Andrew Mente and colleagues1 raises serious concerns of the credibility and rigour of the review process. The paper methodology suffers from flaws that have been repeatedly addressed in the medical literature in recent years and that are ignored.2

[Perspectives] Histories of medical lobbying

The lobbying of government ministers by medical professionals is a live issue. Health professionals around the world have been active in the pursuit of legislative change. In the UK, the AllTrials campaign continues to exert pressure on parliamentarians to force greater transparency in the publication of clinical trial results. This year doctors in Australia refused to discharge child refugees from hospital into detention centres deemed harmful to their health. The lobbying of medical humanitarians such as Médecins sans Frontières in France effected a change in the law there, in 1998, that allowed undocumented immigrants with life-threatening conditions to remain in the country for medical treatment.

[World Report] India’s anti-sex-selection law faces new challenges

India’s law to prevent the use of ultrasound to establish the sex of fetuses could be hampering use of the technology for legitimate purposes. Dinesh C Sharma reports from New Delhi.

Big pathology to get massive windfall at expense of patients, doctors

The AMA has warned that Federal Government proposals to cap pathology collection centre rents will likely drive up patient out-of-pocket costs and could force some medical practices out of business.

In a strongly worded letter, AMA President Dr Michael Gannon has appealed to the Small Business and Family Enterpirse Ombudsman, Kate Carnell, to intervene and help try to convince the Government to drop its plan.

Dr Gannon said the rapid increase in ACC rents since they were deregulated in 2010 had been driven by competition for market share between the two big pathology companies, and the Government itself had attested to the fact that there was no evidence of a link between the pathology referrals made by doctors and ACC rents.

He warned that the Government’s proposed changes would have “a big impact” on medical practices.

Many, the AMA President said, had made decisions about hiring staff and purchasing equipment based on anticipated revenue streams from ACC rents, and the policy would put their finances under strain.

Adrian Rollins

Whistleblower doctors exempt from jail threat

Doctors will no longer be threatened with imprisonment for speaking out about conditions in immigration detention after the Federal Government amended its controversial Australian Border Force Act.

Immigration Department Secretary Michael Pezzullo has confirmed that provisions of the Act have been changed so that secrecy and disclosure rules that threaten whistleblowers with up to two years’ imprisonment no longer apply to health professionals including doctors, nurses, psychologists, pharmacists and dentists.

The backdown follows outcry by the AMA and many other medical groups and individuals against the Act’s secrecy provisions, including the launch of a High Court challenge by the group Doctors for Refugees and the Fitzroy Legal Service.

Doctors for Refugees President Dr Barri Phatafod told the Guardian the decision was a “huge win for doctors and recognition that our code of ethics is paramount”.

The provisions make it a criminal offence for those contracted to provide services to the Department of Immigration and Border Protection to record or disclose information obtained in the course of their work. The penalty is up to two years’ imprisonment.

The operation of immigration detention centres, especially those located offshore on Nauru and Manus Island, has been surrounded by controversy amid claims of assault, self-harm, child abuse and substandard living conditions and medical services.

Groups including Amnesty International have condemned the detention regime, claiming it is causing enormous harm to the wellbeing of asylum seekers and refugees, particularly children.

The AMA has for several years called for the establishment of an independent medical panel empowered to investigate and report on detention centre conditions directly to Parliament.

Doctors have protested that the secrecy provisions in the ABF Act conflict with their ethical duties and their obligations under the Medical Board of Australia’s Code of Conduct, most particularly their paramount obligation to the health of their patients.

These concerns have been magnified by a number of cases in which, it is claimed, authorities have sought to intervene in or override clinical advice on the transfer of detainees in need of medical attention, including the death of Omid Masoumali, who was medically evacuated to Australia from Nauru more than 24 hours after setting himself alight.

The Government denied the intention of the law was to prevent doctors from speaking up on behalf of their patients, and earlier this year Immigration Minister Peter Dutton said he thought it unlikely that health practitioners would be prosecuted under the Act.

But it was revealed that Dr Peter Young, who oversaw the mental health care of detainees for three years, was the subject of Australian Federal Police investigation, including access to his electronic communications and at its most recent National Conference, the AMA passed an urgency motion asking the Federal Council to “look into the matter” of AFP surveillance of doctors.

Dr Young told the Guardian the Government made the amendment because it wanted to avoid legal scrutiny of its policy.

“It’s a big backdown from the Government, and they’ve made it because they didn’t want to go to court, they knew they were going to lose, and they didn’t want their planning and policies discoverable in an open court. That’s what it’s about,” he said.

Adrian Rollins