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Preference: Law

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Reappraising community treatment orders — can there be consensus?

Community treatment orders have become standard practice without serious consideration of the underlying research base

Community treatment orders (CTOs) require someone with a mental illness to follow a treatment plan while living in the community.1 Initially, debate focused on the ethical justification for CTOs, but subsequently shifted to their effectiveness. These considerations are particularly relevant to Australia as a few states, such as Victoria, have among the highest rates of CTO use in the world.2 Further, CTOs may also be incompatible with Australia’s obligations to the United Nations Convention on the Rights of Persons with Disabilities.3 Here, we present a consensus from two authors who have previously expressed very different views on the use of CTOs.1

We note, at the outset, a lack of clarity about the purpose, or purposes, of CTOs. Are they to reduce revolving-door admissions, provide a less restrictive alternative to involuntary admission, prevent violence by people with severe mental illness, or increase stability and promote recovery? These different aims involve a range of different outcomes: hospital use, perceived coercion, violent acts and quality of life. Uncertainty about their purpose is compounded by the range of different interventions. Interventions include clinician-initiated CTOs or supervised discharge and court-ordered outpatient committal. Supervised discharge coexists with CTOs in several countries including Canada and the United Kingdom.4

CTOs can be either “least restrictive” or “preventative” in function. “Least restrictive” orders are an alternative to involuntary hospitalisation in a person who would otherwise meet the criteria for inpatient commitment. By contrast, “preventative” orders aim to avoid relapse and hospitalisation where someone is at risk but does not currently meet the criteria for compulsory admission. Australian CTOs are clinician-initiated and contain elements of both. They are used either on discharge from hospital, or in the community, and last up to 12 months in Victoria, but less elsewhere. In contrast to many other countries where CTOs can only be used if the person has been previously hospitalised, CTOs are often used as an alternative to admission.

Australian patients on CTOs are typically younger males, with schizophrenia or serious affective disorders, frequent admissions, poor adherence and a forensic history. Indigenous status and/or rurality are not associated with CTO placement, possibly reflecting the availability of services to administer the order in remote areas.5

Research findings of health service use

Before-and-after studies suggest that compulsory community treatment led to increased follow-up with clinical services, a reduction in inpatient admissions and reduced lengths of stay in hospital. Subsequent controlled studies, using matching or multivariate analysis, confirmed increased follow-up with mental health services, as well as improved forensic outcomes, but not reduced hospitalisation6,7

Only randomised controlled trials (RCTs) can fully control for potential confounders. There have been three pragmatic studies on the effectiveness of CTOs: two in the late 1990s in North Carolina and New York,8,9and one more recently in the UK.10 None of these demonstrated statistically significant reductions in hospitalisation or improvements in health and forensic outcomes for patients on CTOs.

The two US studies have been the subject of considerable debate. Both excluded patients with a history of violence from randomisation and had high attrition rates resulting in selection bias and reduced study power. In one study, there was also concern about adherence to the research protocol and a smaller than expected sample size.9 A subsequent meta-analysis of the two US studies did not change the negative findings, but only addressed study power, not the other issues.4,7

A non-randomised post-hoc analysis of the North Carolina study reported that CTO placement of more than 180 days was associated with positive outcomes, including decreased hospitalisation and violence.8 However, such an analysis potentially introduced a type of selection bias that randomisation is designed to avoid: individuals may have been maintained on a CTO precisely because they were doing well.

The most recent RCT was the Oxford Community Treatment Order Evaluation Trial (OCTET) in the UK.10 This was a study of clinician-initiated treatment, as opposed to court-ordered interventions, like those examined in the two US RCTs, and therefore is more applicable to other countries with similar provisions. The study randomised patients discharged from hospital to an experimental group (CTOs) or a control group (extended leave under Section 17 of the UK Mental Health Act 1983) and compared their outcomes at 12 months.10 Unlike the US studies, patients with a history of violence were included.

There were no differences in readmissions or length of stay between patients on CTOs and patients in the control group. However, subjects were only included if they were equally suitable for a relatively short period of Section 17 leave or a CTO. Patients who might have especially benefited from a CTO may therefore have been excluded. Further, around 20% of those eligible lacked the capacity to consent or refused to participate. In addition, physicians could make clinical decisions irrespective of the initial randomisation, resulting in over a fifth of those in either arm swapping treatments. A sensitivity analysis to remove these protocol violations may, in turn, have left the study underpowered given the authors’ own calculations.10It will also have not removed the possibility that Section 17 patients who were swapped to a CTO might have been more severely ill than those remaining on Section 17 leave as per the protocol. Finally, the UK trial did not compare CTOs with voluntary treatment but with another type of compulsory community treatment. Although the length of initial compulsory outpatient treatment differed widely between the two groups (medians of 183 days v 8 days), Section 17 patients averaged 4 months on some form of compulsory treatment — a long time for control patients supposedly under voluntary care. This time in compulsory care was mostly due to protocol violations such as the Section 17 patients being changed to CTOs. The lack of difference in outcomes might therefore be explained by the two types of intervention being similar.

In conclusion, the evidence suggesting that CTOs reduce hospitalisation comes primarily from before-and-after studies and the post-hoc analysis of the North Carolina RCT. Most studies with randomised or matched controls have failed to show an effect. However, methodological issues with all the study designs, including the three RCTs, mean that the results have to be interpreted with caution.

Other outcomes

Outcomes in health service use may not reflect outcomes in other important areas such as quality of life or social functioning. The North Carolina RCT reported that subjects on a CTO were significantly less likely to be victimised, but also more likely to report perceived coercion.4,8 The effect on stigma was not reported. In terms of other outcomes, there is no RCT evidence for differences in treatment adherence, social functioning, homelessness, mental state, quality of life and arrests.4,8,9 However, in the case of the forensic outcomes, it is important to note that two studies excluded patients with a history of violence.

Other important or rare outcomes, such as mortality, cannot easily be assessed by an RCT. However, epidemiological studies have suggested that CTO cases have reduced mortality rates compared with control patients after adjusting for confounders, possibly by improving physical care through increased contact with community psychiatric services.11

Implications

We suspect that CTOs may initially increase the likelihood of admission because of increased monitoring in the community. Their effect on other outcomes is less clear. In view of the continued uncertainty about the effectiveness of CTOs, what should clinicians and legislators do? As CTOs are coercive, clinicians have a responsibility, irrespective of their effectiveness, to use CTOs judiciously and only if less coercive approaches have failed. Of concern is the marked variation in the use of CTOs in different jurisdictions.2 While it is unclear if this indicates overuse or underuse, clinicians should avoid the temptation to routinely place patients on CTOs. In addition, one potential conclusion from the UK OCTET study is that briefer conditional leave may suffice for some patients and should therefore be considered when both CTOs and conditional leave are available.

Policymakers must recognise that CTOs are a vehicle for delivering services and are not an alternative to providing care. Governments should also avoid naming the relevant CTO legislation after victims of violence by people with mental illness; examples include Laura’s, Kendra’s and Brian’s Law.1Naming CTO legislation after victims of violence is stigmatising and perpetuates an erroneous belief that people with mental illness are dangerous. Also, while there is non-randomised evidence that CTOs may reduce violence by individuals with untreated illness, this has not been confirmed in subsequent RCTs.8,9 Further, CTOs cannot prevent all potential violence as many individuals only come under professional care after they have offended, and others are inaccurately assessed as at low risk of violence.

Future directions

There is sufficient uncertainty about the effectiveness of CTOs to warrant further RCTs. Trials should have adequate sample sizes with minimal exclusion criteria and compare patients on CTOs with control patients receiving entirely voluntary care, as opposed to compulsory treatment of any form. Multiple outcomes should be assessed — not simply hospitalisation — and the optimum length of treatment should also be evaluated. Given the difficulties of achieving a balance between intervention and control arms, as well as the complexities of obtaining informed voluntary consent, we also need complementary well conducted, large-scale, quasi-experimental and naturalistic studies with rigorous multivariable statistical controls. In addition, while individuals on CTOs feel coerced, there is less understanding about the relative importance of this coercion vis-a-vis other negative outcomes.8

Conclusions

CTOs have become standard practice in Australia without questioning of the wide variations in their use or their research base. When evidence of clinical effectiveness is unclear, health policy is more likely to be shaped by political and social factors. Given several Australian Mental Health Acts are under review, the issue is too important to be uninformed by reliable data.

Complaints system overhaul uncertainty

The nation’s health ministers have put off consideration of a much-anticipated overhaul of the flawed doctors complaints system until August despite evidence it is causing severe distress and anxiety for many medical practitioners.

At its April 17 meeting, the COAG Health Council said consideration of the recommendations of the National Registration and Accreditation Scheme for Health Professionals review conducted by former WA Health Director General Kim Snowball, which is expected to propose changes to the notifications system, had been held over until mid-year.

In submissions to the review, the AMA called for major changes in the way complaints against doctors are handled.

The Association said there needed to be improved screening of complaints and notifications, greater transparency and fairness, and changes to make the scheme more responsive to medical practitioners and accountable to the medical profession.

AMA Vice President Dr Stephen Parnis said the notification process was often arduous and lengthy, with more than 30 per cent of investigations still open after nine months.

There are concerns the findings of the Snowball review have been pre-empted by the Australian Health Practitioner Regulation Agency, which last year released an action plan of changes to the complaints system.

Dr Parnis said AHPRA wanted more information to be provided to complainants, and a greater focus on improving the experience for consumers, when “in fact, efforts need to be directed to improving the investigation process – that is, the practitioner experience. Medical practitioners and consumers, equally, want a regulatory scheme that is timely, fair, transparent and effective.”

The Snowball review also considered mandatory reporting rules for doctors treating other medical practitioners amid concerns they are deterring people from seeking treatment.

Under the National Law, doctors in all states and territories except Western Australia are required by law to notify the Australian Health Practitioner Regulation Agency (AHPRA) if they believe a health practitioner they are treating has practised while drunk or on drugs, has engaged in sexual misconduct, has provided care in a way significantly at odds with accepted professional standards, or has an impairment that could put patient safety at risk.

The AMA has urged that other states adopt WA’s policy of providing an exemption from reporting doctor-patients with an impairment.

Adrian Rollins

National system urgently needed to counter doctor shopping, drug deaths

Medical defence organisation Avant has joined calls for a national system to provide a real-time record of patient prescriptions amid an alarming rise in doctor shopping and deaths and hospitalisations involving the use of prescribed drugs of dependence.

Avant said the lack of national system to track prescriptions was putting patients at risk and leaving doctors prescribing opioids and other strong pain relievers exposed to legal action by depriving them of vital clinical information.

“Doctors are stuck. It’s like they’re prescribing blind, as they don’t have the benefit of the complete clinical picture,” Avant’s Senior Medical Advisor Dr Walid Jammal said. “Avant is adding its voice to those of a number of coroners, health groups and colleges calling for a national real-time prescription monitoring system as a matter of urgency.”

In the past two decades there has been a 15-fold increase in the prescription of opioids, and state coroners have expressed alarm at a concurrent jump in the abuse of prescription drugs, leading to dependency, harm and death.

In 2013, the Coroners Court of Victoria reported that almost 83 per cent of drug-related deaths involved prescription drugs, predominantly opioid analgesics and benzodiazepines.

Adding to the complexity, many GPs face demands from patients addicted to prescription drugs, or who want to sell them on the black market, Avant said, warning “this can lead to inappropriate prescribing to patients who should not receive drugs of dependence, and inappropriate non-prescribing to patient who should receive them”.

In a position statement on the issue released on 23 April, Avant said the prescription of drugs of dependence was becoming an increasingly legally and clinically fraught area of medical practice, with GPs in particular falling foul of often confusing and contradictory laws and regulations regarding their use.

The defence fund said that since 2009 it had seen a 56 per cent jump in calls to its medico-legal advisory service from doctors prescribing drugs of dependence, and the issue was the cause of more than 230 claims made against medical practitioners, including accusations of over-prescribing, prescribing without authority and denial of a prescription, underlining the extent of uncertainty and concern among the medical profession.

Altogether, more than a fifth of doctor professional misconduct cases involved illegal or unethical prescribing as the primary issue, Avant said, and argued that the incidence could be reduced through better education about the legal and clinical aspects of prescribing drugs of dependence.

“In Avant’s experience, many practitioners have little knowledge of their legal obligations around prescribing drugs of dependence and the regulations applicable in their state. In our view, there is also confusion amongst practitioners over the role of the PBS in providing authority to prescribe certain medications,” it said.

Almost 90 per cent of doctors surveyed by Avant backed the call, and three-quarters said a national real-time prescription monitoring system would help them.

Coroners in three states have made repeated recommendations for the establishment of such a system, and Avant said its introduction was now a matter of urgency.

“This system will go towards supporting the safety of patients and minimising the risk of doctor shopping for the purpose of drug diversion or on-selling,” the defence fund said.

Adrian Rollins

AHPRA Prescribing Working Group

By Associate Professor Robyn Langham, Chair, Medical Practice Committee

AHPRA and the Chairs of the National Boards have convened a Prescribing Working Group (PWG) with the aim of developing a governance framework to support the development and review of National Boards’ regulatory policy for prescribing scheduled medicines. 

I represent the AMA on the PWG.

The AMA welcomes the establishment of the PWG.

In our view, the Intergovernmental Agreement and the Health Practitioner Regulation National Law Act 2009 have not delivered adequate safeguards for determining the competencies for prescribing rights. 

This has been demonstrated by the fact three health professions in recent years – optometry, nursing and midwifery, and pharmacy – are taking different approaches to expand their scopes of practice with respect to prescribing.

More recently, the Physiotherapy Board applied to the Australian Health Workforce Ministerial Council for approval to endorse the registration of physiotherapists for scheduled medicines under the National Law, before the Board had worked through the process of ensuring appropriate accreditation standards and programs of study for prescribing practice were available.

The approaches adopted by these Boards have not conformed with the frameworks set out in the National Prescribing Service (NPS) Competencies Required to Prescribe Medicines, which establishes the competencies that health professionals need in order to safely, appropriately and effectively prescribe, or in Health Workforce Australia’s Health Professionals Prescribing Pathway (HPPP), which provides a structure for health professional National Boards and Accreditation Councils to make their education requirements, competency standards and assessment processes nationally consistent.  

There is no high level evidence that independent non-medical prescribing is safe for patients or cost‑effective for the health system.

The current process of Ministerial sign-off on ad hoc approaches to non-medical prescribing that do not involve first establishing the education and training standards, practitioner competencies, and accredited education and training courses, is not sufficient to safeguard patient safety or the quality use of medicines.

For the work of the PWG to be effective, there needs to be a mechanism for establishing a rigorous governance framework that requires the Boards to work together to ensure consistent standards of education and training, and of practice, underpinning prescribing rights. This would provide the community with the necessary assurance that new prescribing rights are adopted safely, in accordance with the NPS and HPPP frameworks.

Importantly, the process of expanding scope of practice to prescribing scheduled medicines needs to be supported by a robust review mechanism that validates regulatory policy compliance and rationalises cost effectiveness.

The evidence base for safety and cost-effectiveness is unlikely to increase without arrangements by the professions or their Boards to evaluate and review the expanded scopes of prescribing practice they adopt.

The AMA will continue its strong advocacy for robust regulatory oversight for safe practitioner prescribing practice. 

The PWG meets quarterly by teleconference, and the next meeting is scheduled for 7 May.

Big Food’s resistance to health stars crumbling

Food industry resistance to the front-of-packet nutrition star rating system is crumbling, with cereal giant Kellogg’s the latest to adopt the labelling scheme for its products.

Almost two years after the Health Star Rating system was approved by the nation’s food and health ministers, Kellogg’s has announced that, from June, the labelling scheme would be introduced across all 37 of its cereal products.

Under the system, which the AMA was involved in developing, food is awarded between a half and five stars depending on its nutritional value. The label also includes a panel detailing sugar, saturated fat, sodium and energy content.

While some Kellogg’s products, including All Bran and Guardian, have been awarded five stars under the scheme, and the majority have four or more stars, several varieties aimed at children, including Coco Pops, Fruit Loops, Crunchy Nut and Nutri-Grain have just two stars and one, Crispix, has earned just 1.5 stars.

Assistant Health Minister Fiona Nash said that Kellogg’s adoption of the voluntary scheme meant that soon the vast majority of breakfast cereals would carry a Health Star Rating, making it easier for “time-poor parents [to] make quick, informed choices…without taking precious time reading labels”.

Monster Health Foods Company was an early adopter of the scheme, and other manufacturers has since joined them, including Sanitarium, Nestle/Uncle Toby’s, Food for Health, Goodness Superfoods, Freedom Foods, Greens General Foods, Coles home brand and Woolworths’ ‘Macro’ brand.

The increasing adoption of the scheme by industry has despite fierce resistance from some manufacturers.

Major food companies including McCain, Mars, PepsiCo, Mondelez, George Weston and Goodman Fielder are yet to implement the scheme.

A Mondelez spokeswoman told Fairfax Media the company, which owns of Kraft, Belvita and Philadelphia, was resisting the scheme because it was flawed.

“Our view is that the concept and formula underpinning the voluntary system fails to account for individuals’ dietary requirements and takes an unrealistic view of portion sizes,” she said.

The resistance has come despite industry’s close involvement in developing the scheme over a two-year period prior to its adoption by the nation’s food and health ministers.

Industry representatives publicly expressed dissatisfaction soon after the system’s formal adoption, and a Federal Health Department website promoting the Health Star Rating system was controversially taken down in early 2014 at the direction of Senator Nash’s office.

The Minister’s then-Chief of Staff, Alistair Furnival, who had directed the take-down, was subsequently forced to resign after it was revealed he co-owned a consultancy that had major food manufacturers among its clients.

The website was reinstated last December, a move welcomed at the time by AMA Vice President Dr Stephen Parnis, who said giving consumers quick and easy nutritional information was an important tool in helping improve food choices and reducing obesity.

Estimates suggest that almost two-thirds of adults, and a quarter of children, are overweight or obese, meaning a huge proportion of the population will be at risk of diabetes, heart disease, stroke and other complex, chronic and expensive health problems unless more is done to trim the nation’s waistline.

Dr Parnis said he hoped that the Health Star Rating scheme would encourage manufacturers to reformulate their products and make them more nutritious in order to earn more stars.

Manufacturers have four years to voluntarily adopt the system, and Dr Parnis said the AMA would support a move by the Government to subsequently make it mandatory.

The Health Star Rating System website can be viewed at:

http://www.healthstarrating.gov.au/internet/healthstarrating/publishing.nsf/content/home

Adrian Rollins

 

Patient info could be caught in data net

The AMA has raised concerns the Federal Government’s contentious data retention laws could be used to compromise patient privacy and potentially undermine the doctor-patient relationship.

AMA President Associate Professor Brian Owler has written to federal MPs including Attorney-General George Brandis, Communications Minister Malcolm Turnbull, Shadow Attorney-General Mark Dreyfus and Shadow Communications Minister Jason Clare raising concerns about the potential for the laws to be used to gather detailed information about a person’s medical condition and health status.

“Metadata can potentially be used to create a profile of an individual based on access to health services,” A/Professor Owler wrote. “This might include the services they may call, emails to and from health providers, SMS appointment reminders and the like. When aggregated, this information could reveal a great deal about someone’s health status.”

Under the laws, telephone companies and internet service providers are required to retain the details of every electronic communication they handle, including the identity of a subscriber and the source, destination, date, time, duration and type of communication. The information stored, known as metadata, does not include the content of a message, phone call, email or an individual’s web-browsing history.

Under the legislation, passed with bi-partisan support late last month, 85 security and policing agencies will have access to an individual’s metadata for up to two years after it is created.

The Government has argued that the laws are crucial to thwarting terrorist activities and preventing serious crime, and has sought to reassure the public that the powers would be used carefully and sparingly.

But law experts and civil liberties groups have raised fears about scope for intrusion on individual privacy.

University of New South Wales law professor George Williams wrote in The Age that the laws would “permit access to the data of every member of the community. Where, for example, the information relates to doctors and their patients, or lawyers and their clients, a government agency will not need to gain a warrant, or to consider whether accessing this information is in the public interest.”

In his letter to the MPs, A/Professor Owler noted that the Law Council of Australia had also expressed concern about the detail of the legislation’s wording, “including with regard to potential access to health information”.

Greens Senator Penny Wright, who was among those who opposed the legislation, warned the measure could have the effect of deterring people from seeking medical help, including online support services.

“With [the] increasing use of online services for mental health, there is a serious risk that this Bill will undermine people’s trust in these online services, with a flow-on risk to access to mental health services and the mental health generally,” Senator Wright said in Australian Doctor.

A/Professor Owler has told senior Coalition and Labor MPs they need to address such concerns “to assure people and health professionals alike that the privacy of health information remains protected”.

Adrian Rollins

 

AMA in the News – 7 April 2015

Your AMA has been active on policy and in the media on a range of issues crucial to making our health system better. Below is a snapshot of recent media coverage.

Print/Online

E-health record scheme a $1b flop, Hobart Mercury, 27 February 2015
The botched Personally Controlled Electronic Health Record program has been operating for nearly three years but fewer than one in 10 Australians has one. AMA President A/Professor Brian Owler said the scheme remains in limbo, and to have spent that much money and yet still not have anything of widespread value was terrible.

Upfront payments for doctors, Australian Financial Review, 3 March 2015
Health Minister Sussan Ley could end Medicare’s universal “fee for service” approach and pay GPs a lump sum per patient, rather than for each visit. Ms Ley has been in constant contact with AMA President A/Professor Brian Owler about potential changes to Medicare.

Dumped policy to cost $1bn, The Australian, 4 March 2015
Tony Abbott has dumped the GP co-payment but maintained a freeze on Medicare payments to general practitioners. AMA President A/Professor Brian Owler warned the freeze would force bulk billing rates down and increase out-of-pocket expenses for private health insurance policyholders.

Medicare rebate freeze to stay, Australian Financial Review, 4 March 2015
The Federal Government will keep more than $1 billion by freezing indexation of Medicare rebates, but has dumped the GP co-payment. AMA President A/Professor Brian Owler welcomed the decision to axe the co-payment, but said keeping the Medicare rebate indexation freeze was lazy reform.

Ley rules out bulk billing means test, Australian Financial Review, 5 March 2015
Health Minister Sussan Ley has ruled out means testing bulk billing as fix in the search for savings to replace the dumped $5 GP co-payment. The Minister said the Government will persist with its search for policies that would impose a value signal on Medicare. AMA President A/Professor Brian Owler said he was happy to co-operate with Ms Ley but did not agree a price signal had a place in primary care.

Don’t be shy about health, MX Sydney, 5 March 2015
New research shows Australians are still choosing to suffer in silence, instead of talking about an awkward health problem. AMA Chair of General Practice Dr Brian Morton said self-treating basic conditions is fine, but alarm bells should ring if the conditions are recurring.

Co-payment could still happen as GP gap-fee option considered, The Age, 9 March 2015
Despite declaring its Medicare co-payment dead, the Government is considering proposals to give GPs the option of charging gap fees for bulk billed patients. AMA President A/Professor Brian Owler said the AMA had long supported such a change, which he said would benefit patients who are currently privately billed.

Why we can’t keep trusting celebrity diet books, Women’s Weekly, 10 March 2015
AMA Vice President Dr Stephen Parnis said we live in an era where people sometimes equate celebrity with expertise, which is not the case. At best, alternative health and diet advocates may advocate something which is supposed to be therapeutic, but actually has no effect. But, at worst, it can be dangerous, he warned.

‘Price signal’ would hit old, poor hardest, The Age, 19 March 2015
Patients who visit the doctor most often tend to be older and poorer than those who visit their GP less, and would be hardest to hit by the introduction of a price signal. AMA President A/Professor Brian Owler said the data undermined the arguments of some proponents of a Medicare co-payment.

Valley of the unwell, The Herald Sun, 19 March 2015
The Goulburn Valley has emerged as the sickest spot in Victoria, with more than one in six residents seeing a GP more than 12 times a year. AMA President A/Professor Brian Owler said the report showed people who most frequently visited their GP have complex and chronic conditions.

Make vaccination law, The Sunday Telegraph, 22 March 2015
The Sunday Telegraph has launched a national campaign for pregnant women to get free whooping cough boosters in the third trimester. AMA President A/Professor Brian Owler called on Federal Health Minister Sussan Ley to fund the boosters.

Call to name medical ‘bad apples’, Sydney Morning Herald, 24 March 2015
Medical specialists who charge exorbitant fees should be named and shamed in a bid to rein in excessive charging. AMA Vice President Dr Stephen Parnis said more doctors than ever were accepting fees set by private health insurers, and almost 90 per cent of privately insured medical services were delivered with no out-of-pocket cost to the patient.

Doctors to anti-vaxxers: you’re endangering kids, The News Daily, 24 March 2015
AMA Vice President Dr Stephen Parnis told The News Daily that anti-vaccination groups don’t know better than the weight of evidence from the medical and scientific profession.

Misogyny in medicine: don’t put up with it, The Age, 25 March 2015
AMA President A/Professor Brian Owler said he was proud of Australia’s medical profession and added it was challenging to hear assertions that doctors were acting in unacceptable ways, particularly when it came to sexual harassment.  

Radio

A/Professor Brian Owler, 666 ABC Canberra, 18 February 2015
AMA President A/Professor Brian Owler talked about the proposed $5 cut to Medicare rebates and the prospect of a $5 co-payment for GP visits still on the table. A/Professor Owler said the idea floated by the Federal Government had not been raised with him.  

Dr Stephen Parnis, Radio Adelaide, 23 February 2015
AMA Vice President Dr Stephen Parnis said he was concerned about the Trans-Pacific Partnership trade agreement and what it could mean for affordable health care, with fears it could raise the cost of drugs and limit access to biological agents used in treatments.

A/Professor Brian Owler, 666 ABC Canberra, 3 March 2015
AMA President A/Professor Brian Owler discussed the Federal Government’s decision to abandon the GP co-payment. A/Professor Owler said it was a good result for GPs and their patients because the policy was poorly designed.

A/Professor Brian Owler, Radio National, 3 March 2015
AMA President A/Professor Brian Owler talked about the Federal Government dumping the Medicare co-payment. A/Professor Owler said the AMA would not support a mandatory price signal, but did not see it as unreasonable for patients who can afford it to make a modest contribution to the cost of their care.

A/Professor Brian Owler, 4BC Brisbane, 31 March 2015
AMA President A/Professor Brian Owler talked about the Federal Government changing aviation rules to require two people in a cockpit at all times. The AMA is not sold on the idea of doctors who treat pilots being able to break doctor-patient confidentiality if they think a pilot is unfit to fly.

Television

A/Professor Brian Owler, ABC News 24, 3 March 2015
AMA President A/Professor Brian Owler talked about the Government dumping the GP co-payment. A/Professor Owler said the tragedy of this whole negotiation period was that other pressing health issues had been neglected.

A/Professor Brian Owler, Sky News, 3 March 2015
AMA President A/Professor Brian Owler discussed the dumped Medicare co-payment and the Medical Research Future Fund.

A/Professor Brian Owler, Channel 9, 17 March 2015
AMA President A/Professor Brian Owler discussed suggestions that teenagers should undergo a psychological assessment before any cosmetic surgery. A/Professor Owler said cosmetic surgery was the source of a number of patient complaints.

Germanwings tragedy prompts mandatory reporting calls

The AMA has warned that calls for the mandatory disclosure of information around the mental health of airline flight crew could dissuade troubled pilots from seeking necessary treatment.

There have been proposals to require treating doctors to report airline pilots and flight engineers who have mental health problems following the deliberate downing of a Germanwings airliner carrying 150 passengers and crew in the French Alps late last month.

Investigators have concluded that 27-year-old co-pilot Andreas Lubitz deliberately flew the Airbus A320 plane into the side of a mountain on 25 March after locking the plane’s captain out of the cockpit. All on board were killed.

It has been reported that Mr Lubitz suffered bouts of depression, was concerned about his eyesight, and had received treatment for suicidal tendencies before obtaining his pilot’s license.

Last week Germanwings’ parent company Lufthansa revealed that Mr Lubtiz had notified the company of his struggle with depression during his pilot training course in 2009.

The case has prompted some to call for laws requiring medical practitioners to report pilots being treated for mental illness to aviation authorities.

But the AMA and other medical experts have questioned the necessity or usefulness of such a measure.

Australasian Society of Aerospace Medicine President Dr Ian Cheng told Medical Observer Designated Aviation Medical Examiners who gave pilots their compulsory annual health checks were already legally obliged to report any significant health condition.

Dr Cheng said that before Australian aviation authorities decided several years ago to allow pilots to continue flying after a depression diagnosis, as long as they were receiving treatment and met strict conditions, the problem had been driven underground because pilots with depression were afraid of losing their license.

AMA Vice President Dr Stephen Parnis warned against any rush to institute mandatory reporting obligations for airline pilots receiving medical treatment.

“Doctors may disclose information about a patient’s medical record if they judge there is a serious threat to the life, health or safety of an individual or the public,” Dr Parnis told Medical Observer. “The last thing we want is a shopping list of things requiring mandatory reporting. That would undermine the confidence of the patient in the doctor.”

The AMA Vice President said mandatory reporting rules for medical practitioners had been blamed for deterring some doctors from seeking help, and there could be a similar risk with such rules for pilots.

Revelations that Mr Lubitz had notified Lufthansa about his battles with depression is likely to intensify the focus on how to best monitor and manage pilots with mental health issues.

Adrian Rollins

AMA in the News – 7 April 2015

Your AMA has been active on policy and in the media on a range of issues crucial to making our health system better. Below is a snapshot of recent media coverage.

Print/Online

E-health record scheme a $1b flop, Hobart Mercury, 27 February 2015
The botched Personally Controlled Electronic Health Record program has been operating for nearly three years but fewer than one in 10 Australians has one. AMA President A/Professor Brian Owler said the scheme remains in limbo, and to have spent that much money and yet still not have anything of widespread value was terrible.

Upfront payments for doctors, Australian Financial Review, 3 March 2015
Health Minister Sussan Ley could end Medicare’s universal “fee for service” approach and pay GPs a lump sum per patient, rather than for each visit. Ms Ley has been in constant contact with AMA President A/Professor Brian Owler about potential changes to Medicare.

Dumped policy to cost $1bn, The Australian, 4 March 2015
Tony Abbott has dumped the GP co-payment but maintained a freeze on Medicare payments to general practitioners. AMA President A/Professor Brian Owler warned the freeze would force bulk billing rates down and increase out-of-pocket expenses for private health insurance policyholders.

Medicare rebate freeze to stay, Australian Financial Review, 4 March 2015
The Federal Government will keep more than $1 billion by freezing indexation of Medicare rebates, but has dumped the GP co-payment. AMA President A/Professor Brian Owler welcomed the decision to axe the co-payment, but said keeping the Medicare rebate indexation freeze was lazy reform.

Ley rules out bulk billing means test, Australian Financial Review, 5 March 2015
Health Minister Sussan Ley has ruled out means testing bulk billing as fix in the search for savings to replace the dumped $5 GP co-payment. The Minister said the Government will persist with its search for policies that would impose a value signal on Medicare. AMA President A/Professor Brian Owler said he was happy to co-operate with Ms Ley but did not agree a price signal had a place in primary care.

Don’t be shy about health, MX Sydney, 5 March 2015
New research shows Australians are still choosing to suffer in silence, instead of talking about an awkward health problem. AMA Chair of General Practice Dr Brian Morton said self-treating basic conditions is fine, but alarm bells should ring if the conditions are recurring.

Co-payment could still happen as GP gap-fee option considered, The Age, 9 March 2015
Despite declaring its Medicare co-payment dead, the Government is considering proposals to give GPs the option of charging gap fees for bulk billed patients. AMA President A/Professor Brian Owler said the AMA had long supported such a change, which he said would benefit patients who are currently privately billed.

Why we can’t keep trusting celebrity diet books, Women’s Weekly, 10 March 2015
AMA Vice President Dr Stephen Parnis said we live in an era where people sometimes equate celebrity with expertise, which is not the case. At best, alternative health and diet advocates may advocate something which is supposed to be therapeutic, but actually has no effect. But, at worst, it can be dangerous, he warned.

‘Price signal’ would hit old, poor hardest, The Age, 19 March 2015
Patients who visit the doctor most often tend to be older and poorer than those who visit their GP less, and would be hardest to hit by the introduction of a price signal. AMA President A/Professor Brian Owler said the data undermined the arguments of some proponents of a Medicare co-payment.

Valley of the unwell, The Herald Sun, 19 March 2015
The Goulburn Valley has emerged as the sickest spot in Victoria, with more than one in six residents seeing a GP more than 12 times a year. AMA President A/Professor Brian Owler said the report showed people who most frequently visited their GP have complex and chronic conditions.

Make vaccination law, The Sunday Telegraph, 22 March 2015
The Sunday Telegraph has launched a national campaign for pregnant women to get free whooping cough boosters in the third trimester. AMA President A/Professor Brian Owler called on Federal Health Minister Sussan Ley to fund the boosters.

Call to name medical ‘bad apples’, Sydney Morning Herald, 24 March 2015
Medical specialists who charge exorbitant fees should be named and shamed in a bid to rein in excessive charging. AMA Vice President Dr Stephen Parnis said more doctors than ever were accepting fees set by private health insurers, and almost 90 per cent of privately insured medical services were delivered with no out-of-pocket cost to the patient.

Doctors to anti-vaxxers: you’re endangering kids, The News Daily, 24 March 2015
AMA Vice President Dr Stephen Parnis told The News Daily that anti-vaccination groups don’t know better than the weight of evidence from the medical and scientific profession.

Misogyny in medicine: don’t put up with it, The Age, 25 March 2015
AMA President A/Professor Brian Owler said he was proud of Australia’s medical profession and added it was challenging to hear assertions that doctors were acting in unacceptable ways, particularly when it came to sexual harassment.  

Radio

A/Professor Brian Owler, 666 ABC Canberra, 18 February 2015
AMA President A/Professor Brian Owler talked about the proposed $5 cut to Medicare rebates and the prospect of a $5 co-payment for GP visits still on the table. A/Professor Owler said the idea floated by the Federal Government had not been raised with him.  

Dr Stephen Parnis, Radio Adelaide, 23 February 2015
AMA Vice President Dr Stephen Parnis said he was concerned about the Trans-Pacific Partnership trade agreement and what it could mean for affordable health care, with fears it could raise the cost of drugs and limit access to biological agents used in treatments.

A/Professor Brian Owler, 666 ABC Canberra, 3 March 2015
AMA President A/Professor Brian Owler discussed the Federal Government’s decision to abandon the GP co-payment. A/Professor Owler said it was a good result for GPs and their patients because the policy was poorly designed.

A/Professor Brian Owler, Radio National, 3 March 2015
AMA President A/Professor Brian Owler talked about the Federal Government dumping the Medicare co-payment. A/Professor Owler said the AMA would not support a mandatory price signal, but did not see it as unreasonable for patients who can afford it to make a modest contribution to the cost of their care.

A/Professor Brian Owler, 4BC Brisbane, 31 March 2015
AMA President A/Professor Brian Owler talked about the Federal Government changing aviation rules to require two people in a cockpit at all times. The AMA is not sold on the idea of doctors who treat pilots being able to break doctor-patient confidentiality if they think a pilot is unfit to fly.

Television

A/Professor Brian Owler, ABC News 24, 3 March 2015
AMA President A/Professor Brian Owler talked about the Government dumping the GP co-payment. A/Professor Owler said the tragedy of this whole negotiation period was that other pressing health issues had been neglected.

A/Professor Brian Owler, Sky News, 3 March 2015
AMA President A/Professor Brian Owler discussed the dumped Medicare co-payment and the Medical Research Future Fund.

A/Professor Brian Owler, Channel 9, 17 March 2015
AMA President A/Professor Brian Owler discussed suggestions that teenagers should undergo a psychological assessment before any cosmetic surgery. A/Professor Owler said cosmetic surgery was the source of a number of patient complaints.