The Alcohol Mandatory Treatment Act: evidence, ethics and the law

High rates of alcohol-related harms have long troubled the Northern Territory, with per capita alcohol consumption levels about 50% higher than the Australian average, and alcohol-attributable deaths occurring at 3.5 times the national rate.1 The Alcohol Mandatory Treatment Act 2013 (NT) (AMT Act) is the latest measure introduced to combat this issue, permitting “civil commitment” of individuals for residential alcohol rehabilitation for up to 3 months. Civil commitment for alcohol and other drug (AOD) dependence is the “legally sanctioned, involuntary commitment of a non-offender into treatment”.2

We contend that there is little evidence of the scheme’s efficacy, and that the NT Government could adopt more cost-effective alternatives that would not involve the dubious application of a medical intervention to reduce public intoxication, with its concomitant legal and ethical issues.

The Police Administration Act 1981 (NT) provides that, where a person is apprehended by police three times for public intoxication over 2 months, they must be referred for assessment by a senior assessment clinician (SAC) in accordance with the AMT Act. Under the AMT Act, the SAC — who is not required to be a medical doctor — must assess the individual within 96 hours and then request a mental health assessment or make an application to the Alcohol Mandatory Treatment Tribunal (the tribunal). The tribunal need not follow the SAC’s assessment report recommendations, but can make a mandatory treatment order in relation to the person if they meet the same criteria used by the SAC; in particular, that “the person’s alcohol misuse is a risk to the health, safety or welfare of the person or others”; “there are no less restrictive interventions reasonably available to deal with this risk”; and “the person would benefit from a mandatory treatment order” (s 10 of the AMT Act).

The NT is not the first Australian jurisdiction to introduce civil commitment laws to combat alcohol dependence. Victoria replaced its Alcohol and Drug-dependent Person’s Act 1968 with the Severe Substance Dependence Treatment Act 2010, which significantly reduced the amount of time that a person could be detained for the purposes of treatment; it now allows for detention and treatment of a person experiencing severe substance dependence for up to 14 days.

New South Wales replaced its Inebriates Act 1912 with the Drug and Alcohol Treatment Act 2007 and, in 2013, introduced the Involuntary Drug and Alcohol Treatment Program, which allows for initial detention of “identified patients” for 28 days, with an option to extend treatment to 3 months. An inquiry conducted into the operation of the original Inebriates Act, which had permitted civil commitment of patients dependent on alcohol for up to 12 months, described this legislation as “essentially punitive rather than therapeutic, treating dependence on a legal and widely available drug — alcohol — as if it were a criminal offence, and using ‘treatment’ as a means of social control rather than for the benefit of the person”.2 Tasmania’s Alcohol and Drug Dependency Act 1968 is presently under review.

The updated NSW and Victorian statutes remove extended periods of incarceration, providing improved protection of patient rights, better reflecting international best practice. For example, the Victorian legislation allows detained patients the right to obtain a second opinion from a registered medical practitioner with relevant expertise in substance dependence. Conversely, the appropriateness of the AMT Act is questionable, given the paucity of evidence for lengthy civil commitment in treating alcohol dependence and the Act’s limited protection of individual rights.

Evidence, ethics, human rights and international guidelines

Evidence for the use of civil commitment in treatment of alcohol dependence is limited. A systematic review concluded there was little evidence for civil commitment of AOD-dependent people, noting most research suffered from methodological limitations.3 This built on a comprehensive systematic review that determined there was no reliable evidence comparing efficacy of compulsory residential treatment with that of voluntary treatment among non-offenders.4 An Australian National Council on Drugs report similarly concluded that “the empirical evidence for the effectiveness of compulsory treatment is inadequate and inconclusive”.5

In the absence of evidence, expert consensus provides useful guidance on acceptable use of civil commitment. The World Health Organization advises that treatment for AOD emergencies should be for short periods only, and that the patient should be released on completion of withdrawal.6 Where an individual becomes “severely mentally disabled”, civil commitment can only be justified when an effective treatment program and adequate facilities are available, the period of commitment is limited, and the individual’s involuntary status is subject to periodic review.6 The United Nations Office on Drugs and Crime (UNODC) considers short-term detention permissible where individuals are at serious risk of harming themselves or others, but compulsory clinical interventions should cease once the acute emergency has been avoided and autonomy re-established.7 Regarding long-term mandatory treatment, the UNODC concluded that:

Evidence of the therapeutic effect of this approach is lacking… It is expensive, not cost-effective, and neither benefits the individual nor the community. It does not constitute an alternative to incarceration because it is a form of incarceration… With sufficient voluntary treatment resources, appropriate referral for treatment from the criminal justice system, and community mobilization, the residual need to use this form of compulsory/involuntary treatment should decrease until it is not used anymore at all.7

These conclusions reflect human rights and ethical considerations regarding mandatory treatment. Generally, coercive treatment is not permitted under the international right to health, which includes rights to control one’s health and body, and to be free from non-consensual medical treatment.8 States must refrain from applying coercive medical treatments, unless on an exceptional basis (such as treatment of mental illness).9 Restriction of individual rights may be permitted, but state parties bear the burden of justifying such serious measures, which must be proportional to the perceived public health threat.9 Ethicists have also concluded that if temporary mandatory treatment for the purpose of creating autonomy may be ethically justifiable — but restoration of autonomy must be “the end of any moral argument for mandatory treatment”.10

Specific issues concerning the AMT Act

Some welcome changes are being made to the AMT Act following a 6-month review.11 Criminal sanctions for absconding from treatment have already been removed, and the NT Government is presently debating whether to broaden referral pathways into the scheme (for example, through allowing medical practitioners to refer individuals to the program). However, concerns remain regarding the lack of evaluation of the program; the use of what is ostensibly a medical intervention to target a social problem; opacity around tribunal proceedings; the potentially discriminatory application of the scheme to Aboriginal people; and the scheme’s questionable cost-effectiveness.

To date, no formal evaluation of the clinical effectiveness of the program has occurred. The government has provided short vignettes containing patients’ success stories and has released reports containing numbers treated, but with no indication of post-discharge relapse rates.12,13 Given the aforementioned paucity of evidence for civil commitment, this lack of evaluation is concerning.

It is also disturbing that the scheme is openly targeted at “chronic drinkers who are publicly intoxicated”11 — not all problem drinkers. This use of a medical intervention to deal with a perceived social problem should concern clinicians. Even if pathways into the program are expanded to allow medical practitioners to refer patients into the program, as the NT Government is debating, this will not address other shortcomings. Any police power of referral is worrying, particularly given acknowledged risks associated with delays in transfer from police custody to assessment facilities.11

The AMT Act also differs from other jurisdictions in that it is mandatory in respect of the coercive nature of its treatment regime and referral into the program; once a client is referred by police, the SAC has no discretion as to whether to refer them to the tribunal. It is troubling also that the tribunal could reach a different conclusion from that of the assessing SAC, and make a mandatory treatment order in the absence of medical support.

Proceedings of the tribunal are not published, reflecting a lack of transparency in this quasi-judicial process. Concerns have also arisen in relation to procedural fairness under the AMT Act; lack of an advocate or interpreter has previously led to invalidation of a tribunal decision on appeal.14

The AMT Act has also been criticised for de-facto discrimination against Aboriginal people. Reportedly, almost everyone assessed under the AMT Act is Aboriginal.15 Homeless or itinerant individuals are much more likely to fall foul of the scheme. Homelessness rates among Indigenous Australians are up to four times higher than those of non-Indigenous Australians,16 and the practice among them of staying in the “long grass” (living rough) has been well documented.17 When read together with research confirming high rates of alcohol usage among homeless and itinerant Aboriginal people,18 it is unsurprising they are more likely to be referred through the scheme than non-Aboriginal citizens.

The AMT Act may infringe s 9 of the Racial Discrimination Act 1975 (Cwlth), by prohibiting enjoyment of a human right based on race, colour, descent, or national or ethnic origin. Although the scheme could constitute a “special measure” taken for the benefit of Aboriginal people, this would be difficult to justify given that the legislation was not written to apply specifically to Aboriginal people. The High Court of Australia recently determined that a law restricting possession of alcohol on Palm Island in Queensland did constitute a special measure, but in very different circumstances.19 Given the AMT Act goes well beyond restricting possession and severely limits the freedom of movement of affected individuals, a different determination could be reached in this instance. The proposed expansion of referral pathways into the program could mitigate this inherent discrimination, but as the legislation stands, legitimate questions remain regarding its application to Aboriginal people.

Finally, it is disquieting that around $27 million annually is being spent on a potentially discriminatory program lacking in evidence;20 between July 2013 and June 2014, a total of 418 people were referred to the program, representing an approximate expenditure of $64 000 per person.13 There are a number of more cost-effective interventions that could be implemented in place of the AMT scheme, which would represent a significantly less punitive approach towards AOD-dependent people in the NT.

Supply-side interventions, such as restrictions on alcohol pricing and hours and days of sale for licensed premises, have been shown to be effective in reducing harms associated with alcohol consumption.21 Rather than punishing individuals for drinking, such restrictions are targeted at those who stand to profit from alcohol misuse. In respect of treatment interventions, capacity-building among primary health care organisations to manage AOD dependence is more readily justifiable than continuation of the AMT scheme, as the clinical and cost-effectiveness of this approach has also been demonstrated.22 Implementation of any or all of these interventions using the significant funding allocated to the AMT scheme could see enormous benefits flow to the NT population more broadly, rather than providing for the temporary and likely ineffective compulsory treatment of a small number of people.

[Comment] Final results from a pivotal phase 3 malaria vaccine trial

In The Lancet, the RTS,S Clinical Trials Partnership1 report the most recent results from the pivotal phase 3 trial of RTS,S/AS01 malaria vaccine, the fourth major publication from this randomised controlled trial.2–4 The trial enrolled 15 459 infants and young children at 11 centres in seven sub-Saharan African countries: Burkina Faso, Gabon, Ghana, Kenya, Malawi, Mozambique, and Tanzania. Two age groups were included: 6–12 weeks and 5–17 months at first dose. The schedule involved a primary series of three monthly doses, with a booster dose given 18 months later in one of the three trial groups.

World medical leaders join condemnation of detention centre gag laws

The World Medical Association has joined calls for the Federal Government to dump new laws that threaten imprisonment for doctors who speak out about the health of asylum seekers held in immigration detention centres.

As pressure mounts on the Government to amend its controversial Border Force Protection Act to protect whistleblowers, World Medical Association President Dr Xavier Deau and WMA Chair Dr Ardis Hoven have written to Prime Minister Tony Abbott to protest against the law, which they said effectively silenced doctors who addressed the health conditions of asylum seekers.

“This is in striking conflict with basic principles of medical ethics,” Dr Deau and Dr Hoven wrote in their letter. “Physicians have to raise their voice, if necessary publicly, when health conditions of their patients, be those free or in detention, are unacceptable.”

Their criticisms echoed concerns raised by AMA President Professor Brian Owler, who told ABC’s Lateline program that the laws were designed “to intimidate people against speaking out. There is no reason why doctors, nurses, and other health care workers should be stopped from speaking up about concerns that they have for the care of their patients, whether they’re detainees or anyone else in our society.”

The WMA leaders declared their support for doctors who advocate for their patients and speak out.

The recent AMA National Conference unanimously supported a notice of motion from Doctors for Refugees co-founder Dr Richard Kidd asking the AMA Federal Council to lobby the Government to exempt from prosecution medical practitioners who blow the whistle on poor health care in detention centres.

Dr Ai-Lene Chan, a GP who worked at the Nauru detention centre, together with colleagues Dr Peter Young and Dr David Isaacs, has warned that the new laws place doctors working in detention centres in an increasingly invidious position.

“The Australian Border Force Act directly challenges professional codes of ethical conduct, including the safeguard of clinical independence and professional integrity from demands of third parties and governments,” they wrote. “The legislation aims to silence health professionals and others who advocate for their patients.”

Separately, a group of more than 40 health, teaching and welfare workers who have worked at the Manus Island and Nauru detention centres have written an open letter to the Government pledging to campaign against the Border Force Act provisions.

Dr Deau said the provisions of the Border Force Protection Act were “effectively an attempt by the Australian government to gag physicians by making their advocacy for the health care of asylum seekers in Australian detention camps a criminal offence. Such a procedure is not acceptable”.

But Immigration Minister Peter Dutton has attempted to hose down the criticism by declaring that whistleblowers had nothing to fear under the new Act.

“Any person who makes a public interest disclosure, as defined within the Public Interest Disclosure Act 2013, will not be subject to any criminal prosecution under the ABF Act,” the Minister said. “While the Government will take action to protect operationally sensitive information, such as personal information or information which compromises the operational effectiveness or response of our officers, the airing of general claims about conditions in immigration facilities will not breach the ABF Act.”

But Mr Dutton’s statement has so far failed to allay concerns that doctors raising legitimate concerns about the treatment of asylum seekers will not face prosecution.

Royal Australian College of Physicians President Professor Nick Talley said the law “attempts to tie our hands to prevent us from fulfilling our duty for a vulnerable group of children and adults with complex health care needs”.

Adrian Rollins

Detention whistleblowers with ‘legitimate’ concerns have nothing to fear – Dutton

Immigration Minister Peter Dutton has tried to hose down concerns doctors could face two years imprisonment for speaking out about shortcomings in the health care of detained asylum seekers under controversial new laws that came into effect on 1 July.

In a statement issued earlier today, Mr Dutton said the new Australian Border Force 2015 Act would “not restrict anyone’s ability to raise genuine concerns about conditions in detention, should they wish to do so through appropriate channels”.

Critics, including leading medical practitioners and barristers, have complained the laws, which threaten all detention centre staff – including health workers – with imprisonment for any unauthorised disclosure of information, target whistleblowers and will further deepen the secrecy surrounding the operation of immigration detention centres.

The AMA and other medical groups have called for an amendment to the law to explicitly protect health workers and allow them to advocate on behalf of their patients.

AMA President Professor Brian Owler said an Australian Human Rights Commission documenting cases of child sexual abuse at Australian-run detention centres demonstrated the need for greater transparency in their operation.

“One of the problems that we’ve got here is an issue of transparency. I think there are a lot of people, particularly doctors, that have been very concerned about the provision of health care.

“The standard of health care, particularly in offshore centres such as Nauru and Manus Island, is well below that we would expect on the mainland, and I think having some sort of independent health group as there used to be, indeed, to actually oversee that and provide some sort of transparency, that gives the Australian people the reassurance that we’re actually fulfilling at least the obligations of providing good health care to people that are in detention, is something that we really want to carry through.”

“The restrictions placed on doctors working in immigration detention results in health care that cannot be consistent with Australian codes and clinical standards,” the doctors said, noting that pathology tests frequently go missing, IT communications are regularly disrupted and the supply of medicines is underdeveloped.

The doctors warned that the Australian Border Force 2015 Act would only serve to compromise care even further.

It said the restrictions it put in place would fundamentally compromise vital aspects practice like sharing clinical information and research, and engaging in professional discussion.

But Mr Dutton said claims the Government wanted to gag whistleblowers with “legitimate” concerns were wrong.

Mr Dutton said the Australian Border Force would investigate leaks of “operationally sensitive” information, but added “the public can be assured that it will not prevent people from speaking out about conditions in immigration detention facilities”.

Adrian Rollins

Whistleblower doctors face jail threat from today

Controversial laws under which doctors could face two years imprisonment for speaking out about shortcomings in the health care of detained asylum seekers come into effect today.

In a measure critics complain targets whistleblowers and will further deepen the secrecy surrounding the operation of immigration detention centres, the new Australian Border Force 2015 Act legislation, passed by Parliament in May, demands that all detention centre staff – including health workers – take an oath, and threatens two years imprisonment for any unauthorised disclosure of information.

Introducing the legislation, Immigration Minister Peter Dutton told Parliament the measure was necessary to “provide assurance to industry and our domestic and international law enforcement and intelligence partners that sensitive information provided to the Australian order Force and my department…will be appropriately protected”.

But the new legislation has fuelled concerns about a lack of scrutiny and accountability in the operation of immigration detention centres, particularly given the disbandment of the independent Immigration Health Advisory Group in late 2013.

Calls by the AMA and other medical groups for an amendment to the law to protect health workers and allow them to advocate on behalf of their patients have so far fallen on deaf ears.

The Government has also ignored suggestions that responsibility for the administration of asylum seeker health services be transferred to the Health Department, and that a body to provide independent oversight of care be reinstated.

Doctors warn the legislation contravenes clinical independence, which is a fundamental tenet of medical practice, by seeking to make medical practitioners and other health workers subject to the demands of the Government.

Dr Ai-Lene Chan, Dr Peter Young and Dr David Isaacs said the new laws placed doctors working in detention centres in an increasingly invidious position.

“The restrictions placed on doctors working in immigration detention results in health care that cannot be consistent with Australian codes and clinical standards,” they said, noting that pathology test frequently go missing, IT communications are regularly disrupted and the supply of medicines is underdeveloped.

The doctors warned that the Australian Border Force 2015 Act would only serve to compromise care even further.

It said the restrictions it put in place would fundamentally compromise vital aspects practice like sharing clinical information and research, and engaging in professional discussion.

The focus on the treatment of detained asylum seekers is intensifying amid allegations that some detainees, including children, have been sexually assaulted and physically abused.

AMA President Professor Brian Olwer earlier this year highlighted an Australian Human Rights Commission report documenting disturbing cases of sexually and physical assault on children in detention.

Professor Owler said the findings underlined the need to get children out of detention.

“Detention is not a safe place for children and this report clearly defines that by the number of assaults, including sexual assaults, unfortunately, that have happened to children, but also the effects on children’s health, particularly mental health,” he said at the time.

Professor Owler said the issue demonstrated the need for greater transparency in the operation of detention centres, rather than deeper secrecy.

“One of the problems that we’ve got here is an issue of transparency. I think there are a lot of people, particularly doctors, that have been very concerned about the provision of health care.

Adrian Rollins

Australia good, but can do better, on heart disease and stroke

Australia has one of the lowest mortality rates from cardiovascular disease in the developed world, but the nation has been told it needs to consider taxes on sugar-rich and unhealthy foods to combat rising obesity and diabetes.

Australia’s cardiovascular disease (CVD) mortality rate fell to 208 per 100,000 people in 2011, 30 per cent below the average among Organisation for Economic Co-operation and Development member countries of 299 per 100,000, and the potential years of life lost to circulatory diseases dipped to 372 per 100,000, 36 per cent below the OECD average of 581 per 100,000.

In a report released overnight, the OECD attributed the nation’s success in driving down deaths from heart attacks and stroke to accessible, high quality health care and effective public health policies, particularly in reducing smoking.

The Organisation said comprehensive tobacco control measures, including a hefty excise, mass media campaigns, advertising and smoking bans and, most recently, tobacco plain packaging laws, had helped drive the smoking rate down to 12.8 per cent last year, one of the lowest in the OECD and well below the average of 20.9 per cent among member countries in 2012.

But the OECD warned the nation needed to overcome several challenges if it was to cement and build upon its success in reducing CVD mortality.

It cautioned that Australia’s high obesity rate – 28.3 per cent, almost double the OECD average of 18 per cent – threatened to drive up the incidence of CVD unless it was addressed, and noted that the nation’s spending on preventive health measures had slipped to just 1.8 per cent of total health expenditure, well below the OECD average of 2.9 per cent.

In its first Budget, the Abbott Government abolished the Australian National Preventive Health Agency and absorbed its functions with the Health Department, heightening concerns of a loss of national focus and leadership on preventive health measures.

The OECD has also echoed warnings from the AMA about the dangers of deterring patients from seeing their doctor by imposing out-of-pocket costs.

AMA President Professor Brian Owler said the Government’s four-year freeze on Medicare rebates would create a patient co-payment “by stealth” by forcing doctors to reduce bulk billing and charge out-of-pocket (OOP) expenses.

The OECD said that Australian patients already faced higher than average out-of-pocket costs, and cautioned that “higher OOP costs will lead to a lower use of primary care services, particularly among the poor”.

Nonetheless, the Organisation said access to primary care in Australia was “generally good”, and the nation’s heavy use of cholesterol-lowering drugs – the highest in the OECD – showed there was ready access to medication.

The observation came two days after research was published estimating that 60,000 patients stopped taking cholesterol-lowering statins after the ABC television program Catalyst questioned their safety.

The OECD said Australians with CVD had access to good quality acute care. The 30-day case-fatality rate for acute myocardial infarction patients was 4.4 per cent, one of the lowest rates in the OECD, while case-fatality for stroke patients was around the OECD average and the proportion of stroke patients treated in dedicated facilities was higher than many other comparable countries.

The OECD said the country needed to curb the rise in obesity if it was to make further inroads into CVD fatality rates, and suggested it consider measures adopted in other countries, such as taxes on unhealthy or sugar-rich food and drinks and the development of nationally-co-ordinated health promotion programs.

Adrian Rollins

Keep GP costs down to win fight against rich world’s biggest killer, OECD says

Decades of success in cutting deaths from heart attacks and strokes are at risk unless governments ensure patients have affordable access to primary health care, the Organisation for Economic Co-operation and Development has warned, adding to pressure on the Federal Government to dump its controversial freeze on Medicare rebates.

As the AMA intensifies its campaign against the four-year freeze, which is set to drive down GP bulk billing rates and force up patient out-of-pocket costs, the OECD has said that affordable and accessible primary care is essential if the world is to build upon a 60 per cent decline in the cardiovascular disease mortality rate in the past 50 years.

In a major report on cardiovascular disease and diabetes released overnight, the OECD said although massive strides had been taken in reducing deaths from cardiovascular disease (CVD), it still remained the most common cause of death in developed countries, and rising rates of obesity and diabetes threatened to slow or even reverse these gains without a greater focus on preventive health, accessible quality primary care and more effective hospital systems.

“The prospects for reducing the CVD disease burden are diminishing, and the pattern of declining mortality is coming to an end or even reversing amongst some population groups, particularly younger age groups,” the Cardiovascular Disease and Diabetes: Policies for Better Health and Quality of Care report said. “Rising levels of obesity and diabetes are reducing our ability to make further inroads into reducing the CVD burden.”

The OECD warned that, on current trends, almost 108 million adults across the OECD would have diabetes by 2030, while an extra 23 million would have greater health needs and a higher risk of complications.

The report paid much of the credit for the decline deaths from heart attacks and strokes in recent decades to public health campaigns, particularly on smoking.

All OECD countries have taken anti-tobacco measures including mass media campaigns, higher taxes, advertising bans and quit services, with the result that between 1997 and 2009 the proportion of adults lighting up daily fell from 28 to 20 per cent.

“Smoking policies have been shown to be highly effective. Tobacco control policies…have saved lives,” the OECD said.

It said that although evidence about the effectiveness of Australia’s world-leading tobacco plain packaging laws was still being gathered, the initiative “may provide the next set of policy instruments for governments to help further reduce the harmful impact of smoking”.

But governments have so far been much less successful in curbing rates of obesity and diabetes, which the OECD said would instead revolve around the strength of a country’s primary health care system.

“Primary care is the centre of the health care system, and is particularly so for CVD and diabetes,” it said, emphasising the importance of affordable and accessible quality care.

“A highly accessible primary care system has the capacity to reduce inequalities in health outcomes and deliver care to those who stand to benefit most,” the report said. “This is particularly important for diseases such as diabetes, which is far more prevalent among lower socio-economic groups.”

It is a timely warning as the AMA ramps up its campaign against the Federal Government’s plan to freeze Medicare rebates until mid-2018.

AMA President Professor Brian Owler has criticised the policy as a “co-payment by stealth” because rising practice costs will force many GPs to dump bulk billing and charge their patients out-of-pocket fees.

Professor Owler said this was concerning because it raised the risk that patients would put off seeing their GP until their health problem became so serious it required hospitalisation.

It is a concern shared by the OECD, which warned that how primary care was funded had “enormous implications” for access to care and health.

“Higher out-of-pocket costs will lead to a lower use of primary care services, particularly among the poor,” it said. “By foregoing routine visits…patients are exposed to greater risk leading to a worsening of health status.

“It is therefore essential that primary care remains highly accessible to all.

“Good access is a necessary requirement to enable primary care practitioners to have regular contacts with patients, assess patient risk, monitor progress, deliver care and adjust treatments when required.”

As part of its report, the OECD examined ways to improve the quality of primary and acute care, including using digital technology to share up-to-date patient information and monitoring their health, as well as pay-for-performance schemes, better hospital access and public reports on the relative performance of hospitals and other health services.

It found that although there was some evidence that pay-for-performance schemes, under which doctors are paid for outcomes – usually in chronic and preventive care – can achieve some improvements, this is often highly contingent on a range of other conditions being in place, meaning great care had to be exercised in implementing such a payment model.

While lauding the success of recent decades in curbing CVD mortality rates, the OECD nonetheless said that it remained the “number one killer” in most member countries, and there were concerns about riding rates of obesity and diabetes, and gaps between recommended health care and that which was actually provided.

The Organisation said it was not just a matter of more money.

“The evidence on what constitutes good quality care has been I the public domain for decades, but many OECD countries are still coming to terms with the changes that need to be made in their health systems to deliver such care,” it said.

The OECD said that one of the most significant challenges was to take evidence about best treatment and make it part of everyday practice.

Adrian Rollins

Curb the drinks to cut the violence

Australian of the Year Rosie Batty has backed calls for a crackdown on sales of alcohol, including an end to 24-hour trading and a buyback of liquor licenses, as part of efforts to stamp out family violence.

Echoing the AMA’s call last year for governments nationwide to take strong action to curb alcohol-related violence, Ms Batty has urged national leaders including Prime Minister Tony Abbott and Opposition leader Bill Shorten to adopt a set of proposals developed by the Foundation for Alcohol Research and Education (FARE) to reduce the saturation of alcohol in the community.

“There is not, and can never be, an acceptable level of family violence,” Ms Batty said. “Prevention must be our ultimate goal, and we must do everything in our power to stop it.”

Ms Batty’s plea has underlined the outcomes of the National Alcohol Summit organised by the AMA last October that called for a consistent national approach to the supply and availability of alcohol, including statutory regulation of alcohol marketing and a review of taxation and pricing arrangements.

AMA President Professor Brian Owler, who convened and led the Summit, said at the time that alcohol misuse was one of the country’s major health issues, with estimates that the damage it caused through violence, traffic accidents, domestic assaults, poor health, absenteeism and premature death, cost the community up to $36 billion a year.

“Alcohol-related harm pervades society. It is a problem that deserves a nationally consistent response and strategy,” Professor Owler said.

In recognition of the fact that often family doctors are the first port of call for victims of domestic violence, the AMA, in conjunction with the Law Council of Australia, last month released a toolkit providing guidance and resources for GPs in helping patients who have been attacked by their partners.

The Supporting parents experiencing family violence – a resource for medical practitioners toolkit can be downloaded at: article/ama-family-violence-resource

The plan to prevent alcohol-related family violence developed by FARE, launched by Ms Batty on 17 June, calls for those applying for liquor licenses to be subject to more stringent approval process, a restriction on trading hours, a liquor licensing freeze or buybacks in saturated areas, an end to 24 hour licences and an extra levy on alcohol to help pay for the costs incurred by governments in responding to family violence.

FARE said alcohol was a factor in 65 per cent of family violence incidents reported to police and almost half of child abuse cases. In addition, more than a third of those who murdered their partner had been drinking prior to the attack.

Chief Executive Michael Thorn said a tough problem called for tough solutions.

“Alcohol’s involvement in family violence is undeniable,” Mr Thorn said. “Governments must acknowledge the vast research and the irrefutable evidence that clearly links the availability of alcohol with family violence, and act accordingly. In practice, that means putting public interests ahead of the alcohol industry and being prepared to say no to liquor licence applications that put people at greater risk of harm.”

The FARE plan echoes the recommendations of last year’s AMA Summit in emphasising measures aimed at preventing alcohol-related harm while simultaneously urging ongoing funding for vital alcohol support and treatment services.

Professor Owler said that although individuals and communities had a role to play, governments – particularly the Commonwealth – needed to be far more active in tackling the issue.

“Too many times we hear that it’s all about personal responsibility. It’s rubbish,” Professor Owler said. “Personal responsibility is important, but we can’t rely on the personal choices of others for our own safety and health. Governments can influence behaviour through deterrents but, most importantly and more effectively, through shaping individual and societal attitudes to alcohol.”

For more information on the AMA National Alcohol Summit, visit: ausmed/end-cheap-grog-and-saturation-marketing-alcohol-summit-tells-govt

The National Alcohol Summit communique can be viewed at: media/ama-national-alcohol-summit-communique

Adrian Rollins

AMA develops GP toolkit to help victims of family violence

AMA President Associate Professor Brian Owler has urged caution in any attempt to make the reporting of family violence mandatory amid an anticipated surge in victims coming forward and seeking help given heightened national awareness of the issue.

Speaking at the launch of a joint AMA/Law Council of Australia toolkit providing guidance and resources for GPs dealing with instances of family violence, A/Professor Owler said that while it was mandatory to report child abuse, governments should be careful about extending this to include adults.

“It’s a complex issue and what you don’t want to do…is set up a system where you might deter people from coming forward and having a conversation with their GP,” the AMA President said. “What you say to the doctor is something that should be kept in confidence, except in very extreme circumstances. We need people to have confidence in actually being able to disclose to their GP that there may be an issue at home and feel safe about doing that.”

The toolkit, prepared by the AMA in consultation with the Law Council of Australia, gives GPs vital information on how to detect and discuss family violence, assess risk, understand legal obligations and provide details of support services and resources for victims and their children.

A/Professor Owler said GPs were often the first port of call for victims of family violence, so it was important that they knew how to discuss the issue and where to access the resources and information needed to help victims and their families.

“There is likely to be more people coming forward…and so it’s important that our GPs are prepared when people do come forward that they have the right resources and the right information to allow and assist them to prescribe the right treatment,” he said.

The pervasiveness of family violence has been underlined by Australian Bureau of Statistics/Australian Institute of Criminology research showing one in six women suffer physical or sexual violence at the hands of their current or former partner, and a quarter suffer emotional abuse.

In a sign of the extent to which family violence is underreported, the study, conducted in 2012, found 58 per cent of women had not reported the attack to police and almost a quarter had never sought advice or support.

The AMA President said family violence could be “a very uncomfortable and difficult issue”, not only for victims but also for GPs, who might have both the victim and the perpetrator as patients.

A/Professor Owler said one of the important features of the toolkit was that it started from the very basics, describing what GPs needed to look for to identify potential victims, and providing crucial advice on how to broach the issue in a way that made people safe and comfortable about talking of what was happening in their home.

He said often patients would see their doctor with an unrelated complaint, and the toolkit helped GPs to ask the right questions as a way of initiating the discussion.

Importantly, he added, the toolkit also talked about what should not be asked when someone disclosed they were a victim of family violence, such as asking ‘what might you have done to avoid this?’, which could be taken as implying blame.

Law Council of Australia President Duncan McConnel said the toolkit was an important step in improving the co-ordination of services to help victims of family violence, which was “not just a law and order issue. It’s a broader issue, and in particular it’s a health issue”.

Mr McConnel said one of the big barriers encountered by victims seeking help was the fact that they had to go through a “sort of revolving door of seeking help from different service, after different service, after different service. It’s been identified as a critical issue”.

He said it was important that doctors helping a victim of family violence knew how to get help and who to contact, including being able to identify safe houses, specialist legal services and other supports.

The Supporting parents experiencing family violence – a resource for medical practitioners toolkit can be downloaded at: article/ama-family-violence-resource

Adrian Rollins

AMA ramps up pressure over asylum seeker health

Mounting evidence about the serious and far-reaching physical and psychological harm being suffered by detained asylum seekers has fuelled calls for the AMA to intensify its lobbying on the controversial policy.

As the medical profession contemplates new laws that threaten to imprison medical practitioners who blow the whistle on shortcomings in the health care of asylum seekers, the AMA National Conference has called for an urgent update of AMA policy to take into account offshore processing and indefinite detention.

Meeting on 31 May in Brisbane, the Conference unanimously passed a motion requesting the AMA Federal Council to review the AMA Health of Asylum Seekers 2011 policy, with particular attention to “new evidence of ongoing and permanent damage being inflicted on detainees as a consequence of the 19 July 2013 law”.

The law, introduced by the Rudd Government, provided that asylum seekers would only be processed in offshore detention centres in Nauru and Papua New Guinea, and would be resettled there – or in a third country – if their claims were successful. None arriving after 19 July 2013 would be settled in Australia.

Darwin-based paediatrician Dr Paul Bauert, who moved the motion, said that as a result of the law, asylum seekers, including children, were being detained for lengthy periods, often in “abominable” conditions.

Dr Bauert told the conference that such detention was causing “on-going damage” to detainees and was unethical.

Speaking in support of the motion, child psychiatrist Dr Choong-Siew Yong said the Government’s policies had created a “toxic environment” in immigration detention centres that would have long-term harmful effects, particularly on children, and urged action.

“As doctors, we cannot just stand by and watch,” Dr Yong said.

The AMA conference also raised concerns about provisions in the Australian Border Protection Act 2015 passed last month under which doctors or any other detention centre workers who disclose health care failures could be imprisoned for up to two years.

The AMA conference unanimously supported a notice of motion from Doctors for Refugees co-founder Dr Richard Kidd asking the AMA Federal Council to lobby the Government to exempt from prosecution medical practitioners who blow the whistle on poor health care in detention centres.

Dr Kidd said doctors had a duty to make the welfare of their patients their top priority, and this inferred both a right and a responsibility to disclose failures in care.

The AMA conference’s call for action has come amid intensifying concern about the health and welfare of asylum seekers, particularly those held in offshore detention centres.

Earlier this year, the results of an Australian Human Rights Commission inquiry were released showing 233 assaults recorded at detention centres between January 2014 and March 2014 involved children, and there were 33 incidents of reported sexual assault.

And the Royal Commission into child sex abuse, which has conducted a large number of high profile public hearings into horrific instances of abuse and the failure of institutions including churches, schools, and group homes to protect children in their care, is investigating the management of the nation’s immigration centres.

Immigration Department Secretary Michael Pezzullo confirmed to a Senate Estimates hearing late last month that the Royal Commission had been in contact with the department and were preparing a notice requiring it to hand over documents.

Video of the Conference debate on the asylum seeker motion can be viewed at: media/ama-national-conference-31-may-2015-session-1

Adrian Rollins