Press Club address covers wide range of topics

AMA President Dr Michael Gannon’s Address to the National Press Club of Australia was both well delivered and well received – covering a wide range of topics of importance to health practitioners and their patients.

It was the second time Dr Gannon had addressed the Press Club, a Canberra-based national institution and forum for policy debate, and will likely be the last as President of the AMA.

During the nationally televised event on August 23, Dr Gannon laid out the AMA’s priorities for the future and highlighted its recent achievements in influencing policy outcomes.

He also fielded a range of questions from the Canberra Press Gallery.

Titled Beyond the Freeze – Time for Heavy Lifting in Heath, Dr Gannon noted there had been numerous changes in the realm of health policy since he last spoke at the Press Club 12 months ago.

“There is no more talk of co-payments,” he said.

“The cuts to pathology and diagnostic imaging bulk billing incentives have been reversed.

“The general practice pathology rents issue has, for the most part, been resolved.

“The Medicare freeze has a ‘use by date’. It can’t come soon enough.”

Dr Gannon said while the AMA wanted an immediate end to the freeze right across the Medicare Benefits Schedule, it didn’t quite get it.

The hour-long address, which involved both a speech and a question and answer session, was moderated by National Press Club President Chris Uhlmann.

Mr Uhlmann at the time was also the ABC News Political Editor, but has since resigned to join the Nine Network as Laurie Oakes’s replacement as Political Editor.

Not one to be passive while in the moderator’s chair, Mr Uhlmann joined in with his Press Gallery colleagues to grill Dr Gannon on a few policy areas.

One insightful exchange was over the emotive issue of euthanasia and the role doctors have in end-of-life care.

“Could you speak just a little bit more on the principle of double effect?” Mr Uhlmann asked.

“I don’t think that most people actually understand that it’s available and actually exists in Catholic canon law, that if someone dies as effect of their pain management being turned up to a point where that’s the secondary effect, that’s something you can even request in a Catholic hospital.”

Dr Gannon’s response was both revealing and informative.

“One of the things you have to be very careful doing when you’re talking on ethical matters is to invoke Catholic canon law, because there are some people who would have great concerns about that,” he said.

“But, Chris, who I know is a scholar in this area, will be able to tell you that this all goes back to St Thomas Aquinas. This is well established in Catholic ethics. And it’s a well-established ethical principle which is very much secular as well.

“But in very simple terms it means that if your primary intention is to relieve suffering, and by secondary effect it has the effect of hastening someone’s life, that is ethically, completely distinct from the intention of ending someone’s life.

“So, if we look at proposed assisted dying laws, the intention is to end the patient’s life. If you look at palliative care, the intention is to relieve pain and suffering. The intention is important.

“I can promise you that palliative care physicians, the nurses who work with them, the teams they work in, they’re a great example of multidisciplinary care for all of us, but they work very carefully and compassionately to provide a level of care which is seven levels above the morphine drip that you’ve all heard of.”

CHRIS JOHNSON

[Series] Palliative care and management of troublesome symptoms for people with chronic obstructive pulmonary disease

People with advanced chronic obstructive pulmonary disease (COPD) have distressing physical and psychological symptoms, often have limited understanding of their disease, and infrequently discuss end-of-life issues in routine clinical care. These are strong indicators for expert multidisciplinary palliative care, which incorporates assessment and management of symptoms and concerns, patient and caregiver education, and sensitive communication to elicit preferences for care towards the end of life.

Questions asked and answered during Press Club appearance

In addition to delivering a wide-ranging 30-minute speech at the National Press Club, AMA President Dr Michael Gannon spent another half hour at the podium fielding questions from the Canberra Press Gallery.

The issues raised by the inquiring reporters ranged from doctors’ fees, to refugee health, to codeine prescriptions, to marriage equality – and a whole lot in between.

On the subject of cost-shifting by the States to patients covered by private insurance who are attending public hospitals, Dr Gannon said he had made the point directly to Health Minister Greg Hunt, that flexibility must be maintained.

“We don’t want a situation where insured patients are prohibited from care in public hospitals,” Dr Gannon said.

“They might live in a rural area where there’s no alternative; no fancy, shiny, private hospital there in the region. It might be the case that a doctor with sub-specialist expertise only works in a public hospital. It may be that they need the intensive care unit that only exists in a public hospital. It may simply be the patient’s choice. So, wherever we land, we must end up with flexibility.

“One of the things that’s led to this problem is the fact that the States and the Territories and the Commonwealth have underinvested in public hospitals. So, the public hospitals are looking for new revenue streams, and sometimes they’re a bit too tricky and clever trying to get hold of insured patients when they’re not actually providing any greater level of care.

“But I also think this is an area where the private health insurers need to step up to their part of the responsibility.”

In his speech, Dr Gannon described the push by insurers for doctors to publish their fees and customer referrals as “dangerous territory”.

In response to questioning about that, he said informed financial consent was very important.

“But I don’t trust a website owned by the insurers to produce un-vetted information about the quality of the magazines in the waiting room, whether or not the receptionist was rude, and I have great concerns about people not being able to obviously interpret quality data,” he said.

“It’s a lot more complicated than a cheesy website might appear.”

Drug testing welfare recipients

The AMA President was highly critical, when he was asked about it, of the Government’s plan to drug test welfare recipients.

“If I had to put a nasty star on the Government’s last Budget, it was this mean and non-evidence-based measure. It simply won’t work,” Dr Gannon said.

“This is not an evidence-based measure (and) will not help. We don’t expect people in most industries to have drug testing before they turn up to work.

“It’s simply unfair and it already picks on an impaired and marginalised group. It’s not evidence-based. It’s not fair. And we stand against it.”

NDIS

On the question of the NDIS eligibility of people with mental health conditions, Dr Gannon said the scheme needed certainty of funding to ensure proper access and eligibility.

“This is going to be a very difficult and vexed issue for Governments now going forward,” he said.

“Talk to the experts. Talk to the GPs, the psychiatrists, the psychologists, the carers who are there providing that care every day. Look at the evidence. Look at what works, and fund it according to what might be expected to work from international evidence, or from talking to home-grown experts here in Australia.”

Same-sex Marriage

On marriage equality, the President said he wouldn’t lecture parliamentarians on legislative approaches, but a risk existed that the wider discussion on the issue will have mental health impacts on people directly affected.

“Equally, we live in a democracy where people are entitled to have their say. I faced criticism of our Position Statement from within the membership, and I have made it very clear that we, as an organisation, are a broad enough church that we can accommodate different views on this topic,” he said.

“And I am not uncomfortable with the Australian people being given their say. We believe that this is an area of discrimination and therefore does have health impacts. We would like to see it resolved. We would like to see the Government, the Parliament, getting on in other crucial areas of public policy, but we are silent on the exact details about how we get there.”

Codeine prescriptions

On codeine, and the AMA’s agreement with the decision to make it available only by prescription, Dr Gannon said the AMA’s position was not a unilateral statement.

“This is very much the AMA supporting the Therapeutic Goods Administration, the TGA, in their independent science-based analysis of the issues,” he said.

“Now, many people might not know that there’s already 25 countries where codeine requires a prescription. Many people might not know that the science tells us that we all metabolise codeine very differently. So for a significant minority of us, we metabolise it in a way that is extremely potent, every bit as powerful as morphine, and is a common cause of death from opioid overdose.

“Not only have we told the Minister we support the TGA’s decision, we are also telling the State and Territory Health Ministers that we do not want to see exemptions from this. That’s wading into very, very dangerous territory, when the independent regulator looking at scientific evidence is overrun by an industry that has a different view.”

Euthanasia

On palliative care and support of doctors who may wish to assist patients to die, he was very clear.

“We have inadequate legislation in most parts of Australia to protect doctors acting ethically and lawfully with inadequate doctrine of double effect legislation,” Dr Gannon said.

“Ninety-nine per cent of end-of-life decisions do not involve requests to die. That is a very, very, very small part of the system.

“And surely the aspiration of all people, whether they favour voluntary euthanasia or not, is to improve palliative care services.

“The AMA Position Statement makes it extremely clear that we understand this is a decision for society: it’s Parliament’s, it’s legislators’. The AMA’s position is that doctors should not participate in these arrangements.”

Refugee health care

Regarding the level of health care provided to asylum seekers in offshore detention, Dr Gannon said the ethical principles were very clear.

People seeking the protection of the Australian Government are entitled to healthcare standards the same as Australian citizens.

“So, that’s a matter of ethics and that’s a matter of law. What we’ve developed over the past 12 months or so is a relationship with the Chief Medical Officer of the Department of Immigration and Border Protection, so that when we receive discussions on individual healthcare episodes we are able to talk about them,” he said.

“… a difficult and vexed issue where a form of medical care, namely termination of pregnancy – which could relatively easily be provided on Nauru – can’t legally be provided because it’s illegal on the island.

“That means that if that cannot be provided, that those patients must be transferred to the mainland. This is a hotly contested political issue. I am not an immigration expert. But I like to think I’m an expert in medical ethics, and I’ve stated our position very clearly as to the health standards that we would expect.”

Private health insurance

On private health insurance, Dr Gannon said agreement must be reached on basic level of cover, or at least better transparency, so people know what they’re covered for.

“The policies that are nothing more than to dodge the tax penalty, they’re junk,” he said.

“The policies that limit you to care in a public hospital, I need to be convinced why they’re any better than being a public patient in our excellent public hospitals.

“Now I don’t want to spend my entire life arguing with the insurers. They have a right to make a profit. In fact they’ve got a corporate responsibility to deliver a profit. But they cannot deliver that profit on the back of diminished services to private patients. And if they don’t get it and they don’t get it soon, they will drive their industry off the cliff.”

CHRIS JOHNSON

The full transcript of Dr Gannon’s Q&A session at the National Press Club can be found here:

media/dr-michael-gannon-national-press-club-q-and

Political message in National Press Club speech

AMA President Dr Michael Gannon has called on all sides of politics to take some of the politicking out of health, for the good of the nation.

Addressing the National Press Club of Australia, Dr Gannon said some health issues needed bipartisan support and all politicians should acknowledge that.

“Some of the structural pillars of our health system – public hospitals, private health, the balance between the two systems, primary care, the need to invest in health prevention – Let’s make these bipartisan,” he said.

“Let’s take the point scoring out of them. Both sides should publicly commit to supporting and funding these foundations. The public – our patients – expect no less.”

During the nationally televised address, broadcast live as he delivered it on August 23, Dr Gannon warned political leaders that the next election was anyone’s to win and so they should pay close attention to health policy.

“Last year we had a very close election, and health policy was a major factor in the closeness of the result,” he said.

“The Coalition very nearly ended up in Opposition because of its poor health policies. Labor ran a very effective Mediscare campaign.

“As I have noted, the Government appears to have learnt its lesson on health, and is now more engaged and consultative – with the AMA and other health groups.

“The next election is due in two years. There could possibly be one earlier. A lot earlier.

“As we head to the next election, I ask that we try to take some of the ideology and hard-nosed politicking out of health.”

In a wide-ranging speech, the AMA President outlined the organisation’s priorities, while also explaining the ground it has covered in helping to deliver good outcomes for both patients and doctors.

The AMA’s priorities extend to Indigenous health, medical training and workforce, the Pharmaceutical Benefits Scheme, and the many public health issues facing the Australian community – most notably tobacco, immunisation, obesity, and alcohol abuse.

“I have called for the establishment of a no-fault compensation scheme for the very small number of individuals injured by vaccines,” Dr Gannon said.

“I have called on the other States and Territories to mirror the Western Australian law, which exempts treating doctors from mandatory reporting and stops them getting help.

“We also need to deal with ongoing problems in aged care, palliative care, mental health, euthanasia, and the scope of practice of other health professions.

“In the past 12 months, the AMA has released statements on infant nutrition, female genital mutilation, and addiction.

“In coming months, we will have more to say on cost of living, homelessness, elder abuse, and road safety, to name but a few.

“Then there are the prominent highly political and social issues that have a health dimension, and require an AMA position and AMA comment.

“All these things have health impacts. As the peak health and medical advocacy group in the country, the community expects us to have a view and to make public comment. And we do.

“Not everybody agrees with us. But our positions are based on evidence, in medical science, and our unique knowledge and experience of medicine and human health.

“Health policy is ever-evolving. Health reform never sleeps.”

The address covered, among other things, health economics: “Health should never be considered just an expensive line item in a budget – it is an investment in the welfare, wellbeing, and productivity of the Australian people.”

Public hospital funding: “The idea that a financial disincentive, applied against the hospital, will somehow ‘encourage’ doctors to take better care of patients than they already do is ludicrous.”

Private health: “If we do not get reforms to private health insurance right – and soon – we may see essential parts of health care disappear from the private sector.

The medical workforce: “We do not need more medical school places. The focus needs to be further downstream.

“Unfortunately, we are seeing universities continuing to ignore community need and lobbying for new medical schools or extra places.

“This is a totally arrogant and irresponsible approach, fuelled by a desire for the prestige of a medical school and their bottom line.

“Macquarie University is just the latest case in point.”

And general practice: “General practice is under pressure, yet it continues to deliver great outcomes for patients.

“GPs are delivering high quality care, and remain the most cost effective part of our health system. But they still work long and hard, often under enormous pressure.

“The decision to progressively lift the Medicare freeze on GP services is a step in the right direction.”

On even more controversial topics, Dr Gannon stressed that the AMA is completely independent of governments.

While sometimes it gets accused of being too conservative, he said, it was not surprising to see the reaction to the AMA’s position on some issues – like marriage equality.

“Our Position Statement outlines the health implications of excluding LGBTIQ individuals from the institution of marriage,” he said.

“Things like bullying, harassment, victimisation, depression, fear, exclusion, and discrimination, all impact on physical and mental health.

“I received correspondence from AMA members and the general public. The overwhelming majority applauded the AMA position.

“Those who opposed the AMA stance said that we were being too progressive, and wading into areas of social policy.

“The AMA will from time to time weigh in on social issues. We should call out discrimination and inequity in all forms, especially when their consequences affect people’s health and wellbeing.”

Last year, the AMA released an updated Position Statement on Euthanasia and Physician Assisted Suicide.

It came at a time when a number of States, most notably South Australia and Victoria, were considering voluntary euthanasia legislation.

There was an expectation in some quarters that the AMA would come out with a radical new direction. But it didn’t.

“The AMA maintains its position that doctors should not be involved in interventions that have as their primary intention the ending of a person’s life,” Dr Gannon said.

“This does not include the discontinuation of treatments that are of no medical benefit to a dying patient. This is not euthanasia.

“Doctors have an ethical duty to care for dying patients so that they can die in comfort and with dignity.”

The AMA also takes Indigenous health very seriously.

Dr Gannon travelled to Darwin last year to launch the AMA’s annual Indigenous Health Report Card, which focused on Rheumatic Heart Disease.

“In simple terms, RHD is a bacterial infection from the throat or the skin that damages heart valves and ultimately causes heart failure,” he said.

“It is a disease that has virtually been expunged from the non-Indigenous community. It is a disease of poverty.

“RHD is perhaps the classic example of a Social Determinant of Health. It proves why investment in clean water, adequate housing, and sanitation is just as important as echocardiography and open heart surgery.

“The significance of challenging social issues like Indigenous health, marriage equality, and euthanasia is that they highlight the unique position and strengths of the AMA.

“The AMA was recently ranked the most ethical organisation in the country in the Ethics Index produced by the Governance Institute of Australia.

“People want and expect us to have a view – an opinion. Sometimes a second opinion.”

Chris Johnson

A transcript of the full address can be found here:
media/dr-gannon-national-press-club-address-0

Attending the House of Delegates meeting of the American Medical Association

BY ANNE TRIMMER AMA SECRETARY GENERAL

The annual meeting of the House of Delegates (HOD) of the American Medical Association (AmMA) is the only event in which all of “organised medicine” in the United States physically comes together at the same time and place.

The program for the annual HOD meeting is immense. There is a mix of open sessions and committee sessions in the lead in the HOD meeting itself. Eight committees meet over the course of two days to work their way through a comprehensive agenda of reports and resolutions that amend existing policy or introduce new policy. The result of the committees’ work is then caucused by the participating representative societies and associations in preparation for debate on the floor of the HOD.

The HOD opens with a formal speech by the President (who completes a one-year term at the close of the HOD meeting) and another by the CEO. The meeting then opens to debate on the reports and resolutions that have come forward from the committees. This takes two days and can continue into a third day of the business isn’t completed.

As an international guest at this year’s meeting in June, I was invited to observe all proceedings and I made the most of the invitation by attending an open forum of the Council on Ethics and Judicial Affairs, two committee meetings, and the HOD meeting.

The conduct of the debate is democracy in action. The Speaker and Deputy Speaker control the debate with great deftness and humour. Speakers line up, as they do at the AMA National Conference, waiting to be recognised to speak.

There were several recurring issues that resonated. The first, and most pressing, was that of access to health care, even more so with legislation introduced by the Trump administration to wind back the Affordable Care Act (ObamaCare) which would have the result that 23 million Americans would lose cover. The legislation (the American Health Care Act or AHCA) is causing deep concern within the AmMA about the likely outcome.

Delegates debated the acceptability of per capita caps under federal Medicaid funding, which are a key element of the AHCA and are being considered for incorporation into the Senate version of the legislation that is still being drafted. The delegates rejected any proposal for caps on the basis that they would weaken States’ ability to respond to enrolment changes, greater care needs or breakthrough treatments.

The tactics of health insurers to deny cover for patients, or to create delays for physicians in trying to secure approval, were raised on many occasions. One of the more interesting debates focused on a resolution for AmMA to advocate for a public option to provide health cover where no insurance cover exists. This aspect of the original ObamaCare legislation was removed as a compromise to get the majority of the legislation through the Congress. AmMA voted to support the inclusion of a public option. The Australian health system was cited in debate as an exemplar of a system where there is public cover but also a right to choose private cover.

The networks established by the insurers are shrinking, often with the result that patients lose the physician they have had all of their lives. The provision of out of network care carries significant cost for patients who are not covered if they need care at a hospital that is not within their insurer’s network. This has an impact on emergency doctors who won’t turn patients away if they present at an out of network emergency department. At times the patient may not even be aware that they are out of network.

The resulting “surprise bills” come about either because the patient has presented out of network or because the cover they have is inadequate for the procedure that is undertaken. Delegates were critical of “outlier” medical colleagues who levied significant bills in these circumstances, attracting the ire of patients and media.

This has led to consideration in several States of a “fair minimum benefit”. However as States have been ratcheting down the benefits paid under Medicare, doctors are concerned that any benefit that is tied to Medicare will be inadequate for the service that is provided. Delegates discussed the potential for an independent database to be used as a reference point for charging (which sounds not dissimilar to the AMA Fees List).

Another example of egregious insurer behavior occurs in emergency departments where the insurer withdraws cover on the basis that the reason for presentation is not an emergency. To overcome this the patient is forced to seek pre-approval.

The issue of physician health was raised on several occasions. The concern is with burnout, exacerbated by the frustrations of dealing with the health insurers in seeking pre-approval for patients, and the electronic health record. Speakers referred to the extensive delays created by the system. Reference was also made to depression and suicide among doctors.

The open session of the Council on Ethics and Judicial Affairs provided a forum for the AmMA to obtain member feedback in the development of a new policy on euthanasia and physician assisted suicide. Among the speakers from the floor were physicians from the five States where it is already legal for doctors to prescribe end of life pharmaceuticals. In California, for example, physicians can choose to opt into the process with 18 per cent currently doing so. The legislation provides multiple safeguards.

Colorado is the most recent State to introduce euthanasia. The State medical society undertook a two year consultation before changing its policy to accommodate the change. In that State a patient must be able to self-administer the medication. However the cost of effective medication can be a barrier to a patient carrying out the euthanasia.

In the State of Oregon where euthanasia has been legal for 20 years, the State medical society has maintained a neutral position.

Notwithstanding that euthanasia is legal in some States, the debate emphasised the need for a better understanding of the role of palliative care and the place of hospice care. Patients at the end of life were often ignorant of the benefits of palliative care.

The address by the outgoing President of the AmMA, Dr Andrew Gurman, highlighted the big issues faced by the AmMA over the previous 12 months. These included the requirements of the health insurers for pre-authorisation of drugs and medical devices before they could be prescribed or utilised in surgery; gun control as a public health issue; the defeat of proposed health fund mergers which would have further reduced access to health care; and physician burnout.

Dr Gurman highlighted what he described as “advocacy at its most basic, human level” when he met with medical trainees who had grown up in the US but now feared deportation under proposed changes announced by the Trump administration.

The Executive Vice President and CEO, Dr James Madara, highlighted that the AmMA recently celebrated its 170^th birthday, having been established in 1847. He identified three strategic areas for current focus in the work of the AmMA:

Practice satisfaction and professional practice;
Medical education; and
Patients with pre-diabetes.

This last point relates to the fact that a staggering 83 per cent of health services in the US are for chronic conditions.

Unsurprisingly an opinion poll released while I was in the US has health as the number one issue for the electorate.

The AmMA’s work on medical education centres on online learning to provide tools and resources to physicians, including the recent release of an online education program on best use of electronic health records. This is part of a project entitled health 2047 (for the 200^th birthday of the establishment of the AmMA) which aims to return to the physician one hour per day of the working week. Many speakers identified that navigating the current EHR system currently consumes up to two days each working week.

The AmMA is also working to protect patients at risk of losing their health cover by expanding meaningful coverage and including safety nets.

Resident mental health is now mandated as part of every residency program.

The contributions from the medical students were among the most compelling. The medical student section put forward a motion calling on the AmMA to be a leader in advocacy on the social determinants of health. The National Academy of Medicine established a framework in 2016 to better understand the social determinants. As several delegates pointed out, without understanding the social context of a patient there may be impacts on the care that is given. Examples provided were a patient living in accommodation with no running water, or with no access to transport to attend a pharmacy to have a prescription filled.

Another significant public health issue that attracted debate is the opioid epidemic in the US which has arisen as a result of the over-prescribing of pain medication.

The organisation

The AmMA’s revenue in 2016 was $323.7 million with a profit of $13.6 million.

The House of Delegates is the supreme policy making body and elects the office-holders, including the President-elect who then becomes President the following year. It also elects the members of the Board of Trustees.

The Board of Trustees is the principal governing body and takes actions based on the policy and directives of the HOD. It exercises broad oversight and guidance with respect to management systems and risk through the oversight of the Executive Vice President (the CEO). It has 21 members who have fiduciary responsibility for the organization and select and evaluate the CEO. The members include a student, a resident, a young physician, and a public member.

The eight Councils are standing, domain based, expert bodies. They are:

Council on Constitution and Bylaws
Council on Ethical and Judicial Affairs
Council on Legislation
Council on Long Range Planning and Development
Council on Medical Education
Council on Medical Service
Council on Science and Public Health
American Medical Political Action Committee.

The Sections and Special Groups represent the constituent groups and provide a channel for outreach and member insights. They are as diverse as the Advisory Committee on LGBT Issues, the International Medical Graduates Section, the Medical Student Section, and the Organised Medical Staff Section.

The HOD draws representation from the State and territorial medical associations (260 delegates) and national medical specialty societies (205 delegates). It has 528 delegates and the same number of alternate delegates. With Past Presidents and observers there are approximately 1200 attendees at the HOD annual meeting.

The rules for participation of a national medical specialty society are complex and are based on the number of its members who are members of the AmMA at the rate of one delegate per 1,000 AmMA members with every eligible national medical specialty entitled to at least one delegate. Similarly every State/territory is entitled to at least one delegate.

In addition delegates represent Federal Services (Air Force, Army, Navy, Department of Veterans Affairs, and the US Public Health Service); AMA Sections; other national societies; and professional interest medical associations.

AmMA represents approximately 25 per cent of American physicians. However as the umbrella body representing the entire profession it is the voice in Washington DC that speaks for all physicians.

Each policy that is put before the HOD has a fiscal note on the likely cost of the proposal if adopted. This is a good discipline in either reducing or refining some resolutions.

Every policy is recorded in PolicyFinder which is an electronic database available online and updated after each meeting of the HOD.

As a final note, every resolution or policy that is put forward is framed as ‘our AMA’ undertaking the specified action. This engenders a sense of ownership and pride in the organisation’s advocacy.

2017 AMA media and advocacy awards

At the 2017 AMA National Conference, six media and advocacy awards were presented.

A new award category was opened for this year’s entries – the Best Public Health Initiative. State and Territory AMAs were invited to nominate an outstanding public health initiative or campaign – other than smoking and tobacco control – launched by their State or Territory Government in calendar year 2016.

Nominated by AMA NSW, The NSW Government, won this award for its campaign to combat childhood obesity. The NSW Health campaign is a comprehensive whole-of-government plan with the specific target of reducing overweight and obesity rates of children by 5 per cent over 10 years.

The judging panel, headed by Public Health Association of Australia CEO Michael Moore, noted that the campaign stood out for its clear strategic directions, and its strong focus on children and young people.

The Best Lobby Campaign 2017 was awarded to AMA Western Australia for their ‘Three-year Employment Contracts for Interns’ campaign.

The successful introduction of the three-year employment contracts for interns is a standout achievement. The reform eliminates the previous system of annual contracts, thereby eliminating both the cost and the stress of interns having to reapply for their jobs on an annual basis.

The judges commented that AMA WA’s policy success should contribute to improved health outcomes across the WA system, with the hope that this initiative may spread nationally over time. In addition, the successful recombination of the Minister of Health and Mental Health is also a noteworthy success for the WA branch.

Best Public Health Campaign from a State or Territory 2017 was awarded to AMA Western Australia for highlighting ‘Australia’s Mental Health Crisis’.

AMA WA has developed a state-of-the-art best practice mental health program that is being recognised Australia-wide as the best of its kind using a dual approach to reach youth at school and adults in the workplace – two groups under severe mental health pressure.

Judges commended the branch on the clarity and quality of the campaign. They said the effectiveness in engaging and delivering its important message pointed to a significant public health intervention that deserved to be recognised.

AMA Victoria received Best State Publication 2017 for ‘Vicdoc’, whichcovers the ethical, political, clinical, and work based issues facing the medical profession in great detail.

Judges commented that the publication was valuable and informative and a must-read for any Victorian doctor. The front covers were simple and with compelling use of images. The standard of writing in this publication was extremely high and very informative.

AMA Victoria was also awarded with the National Advocacy Award 2017 for their cooperation between federal AMA during the introduction of the Victorian Government’s ‘Assisted Dying’ legislation.

AMA Victoria’s actions and commentary on assisted dying have always referenced and reflected AMA Federal’s policy position.

AMA Victoria called for improved funding for palliative care services, and legislative changes to the Doctrine of Double Effect through the enactment of legislation to provide legal certainty to medical practitioners in connection with the accepted clinical practices of double effect and non-provision of futile care.

Judges commended AMA Victoria on its clear and concise submission to the inquiry into a very sensitive and often divisive issue.

Most Innovative Use of Website or New Media 2017 was awarded to AMA Western Australia for their creation of WAhealthfirst.com.au.

This website utilised a new media approach that generates conversation from content advocating AMA WA’s position on key political issues, most relevant to the recent State election earlier this year. An expected outcome of new media is to use technology available to provide clear and easy communication to the user. Judges commended AMA WA in the success of WAhealthfirst.com.au and said it was clear it simplified the voter education process of health policy while also providing the facts.

Meredith Horne

Failing to plan is planning to fail: advance care directives and the Aboriginal people of the Top End

Advance care directives can enable Aboriginal people to fulfil their end-of-life wishes to die in their community

The United Kingdom’s great wartime Prime Minister, Sir Winston Churchill, once said “he who fails to plan is planning to fail”. These prescient words resonate for advanced care planning and end-of-life decision making.

Advance care directives (ACDs) are used in all Australian states and territories, but take different forms and names. In the Northern Territory, they are known as advance personal plans (APPs).1 An APP allows not only for advanced consent decisions in relation to life support and palliative care, but also the appointment of a substitute decision maker. The powers of the substitute decision maker under the Advance Personal Planning Act 2013 can include health and financial matters.1

ACDs have a valuable role for Aboriginal and Torres Strait Islander (respectfully referred to hereafter as Aboriginal) Australians for two important reasons. First, Aboriginal people suffer from higher rates of life-limiting conditions and burden of disability approaching end of life.2 Second, because of their strong connections to land and community, Aboriginal people from rural and remote regions have a strong preference to “die at home connected to land and family”.3 McGrath outlined a fear of dying away from home for Aboriginal patients from remote communities and outstations, who were relocated to tertiary facilities often hundreds of kilometres away.3 Early discussion of end-of-life preferences, with the use of an ACD, could play an important part in preventing unnecessary displacement of patients by allowing those who wish to die in their community to do so.

Nevertheless, the sparse research in this area suggests that advanced care planning is not common place for most Aboriginal people.2,4 Some of the reasons for this include the taboo of death talk, communication barriers, presence of multiple clinicians (with no single professional taking on the responsibility for initiation of discussion), uncertainty in prognosis, availability of family (often limited by distance), scarcity of Aboriginal health practitioners, and the formal, structured approach of an ACD. Regardless, Sinclair and colleagues demonstrated acceptance for ACDs in their qualitative study of Aboriginal people in the Great Southern region of Western Australia.2 Their patients outlined the potential for the ACD to ameliorate family disputes. The authors called for an increased role for the family, use of Aboriginal health practitioners, and a whole-of-community approach in implementing ACDs.2

The NT APP is a formal, structured document, which necessitates English language proficiency and health literacy. Previous authors have suggested that these characteristics make ACDs an ineffective document for many Aboriginal patients.2 Despite the nature of the population of the NT and the Royal Darwin Hospital (RDH), its Aboriginal health practitioners are not required to undertake training in the use of the APP as part of their curriculum. It is these same individuals who have been delegated the task of helping Aboriginal patients to complete their ACDs.2 In a Canadian context, Kelly and Minty have called for less formal documentation of aboriginal patients’ wishes.5 A culturally appropriate, less formal document that allows for immediate and future planning may also be most pertinent in an Australian context. However, this carries with it the peril of operating outside the legal protections afforded by the APP. Perhaps, an option for the NT is the creation of an educational document to help inform Aboriginal people about APPs. Similar documents exist in other states, such as Advance care yarning in South Australia.6 The cultural diversity among the Aboriginal peoples of Australia behoves the development of such a document in the NT.

To further examine ACDs for the Aboriginal people of the Top End, especially in the context of life-limiting illness, Territory Palliative Care, Program of Experience in the Palliative Approach (PEPA) and the Aboriginal Medical Services Alliance Northern Territory plan to conduct focus groups with key stakeholders in the NT. Focus group sessions will be run in conjunction with PEPA workshops over the next 12 months. Focus groups will be scheduled in Darwin, Alice Springs, Katherine, Tiwi Island, Gove, Wadeye, Maningrida and Groote Eylandt. Key issues to be examined include the applicability of the current APP for Aboriginal people, education of Aboriginal health practitioners, the utility of a Top End-specific educational document, and the suitability of a less formal document such as a personal portfolio. Funding is being sought for the focus groups and creation of a culturally appropriate education document. In the interim, a steering committee has been created by the RDH to consider the key issues.

[Perspectives] Admissions and exits

He is vain, angry, self-important, and has sagging, elderly buttocks: Henry Marsh tells us this about himself in his new book Admissions: A Life In Brain Surgery—honest to the point of brutal. This is the life and times of a famous neurosurgeon, entering retirement, who at once seems to be delighted by his renown but also despises it. Marsh names people that he has bitterly fallen out with; shamefully documents how he pulled the nose of a nurse over a dispute about a nasogastric tube; describes his own treatment by a psychiatrist; spells out his guilty mistakes in operating; and describes how, if terminally ill, he would regard palliative care specialists as professionals who “derive their own sense of meaning and purpose from my suffering”.

Federal Budget delivers – Medicare rebate freeze to be lifted

The AMA welcomes much of the health measures in the Federal Budget and commends the Government for taking action on the Medicare rebate freeze.

AMA President Dr Michael Gannon said the Coalition had won back much of the goodwill it lost with its disastrous 2014 Health Budget by this time handing down a Budget with numerous positive health measures.

Dr Gannon said the staggered lifting of the freeze on Medicare patient rebates was well overdue.

“This is a monkey that has been on the back of the Coalition Government since the 2014 Budget that cut significant dollars out of health. This is the chance to correct those wrongs,” he said.

The freeze will be lifted from bulk billing incentives for GP consultations from 1 July 2017, from standard GP consultations and other specialist consultations from 1 July 2018, from procedures from 1 July 2019, and targeted diagnostic imaging services from 1 July 2020.

The lifting of the freeze on Medicare rebates will cost the Government about $1 billion.

“The AMA would have preferred to see the Medicare freeze lifted across the board from 1 July 2017, but we acknowledge that the three-stage process will provide GPs and other specialists with certainty and security about their practices, and patients can be confident that their health care will remain accessible and affordable,” Dr Gannon said.

“Lifting the Medicare rebate freeze is overdue, but we welcome it.”

Dr Gannon also described many of the health policy breakthroughs in the Budget as a direct result of AMA lobbying and the consultative approach of Health Minister Greg Hunt.

“Minister Hunt said from day one in the job that he would listen and learn from the people who work in the health system every day about what is best for patients, and he has delivered,” Dr Gannon said.

AMA advocacy has also seen, in this Budget, the reversing of proposed cuts to bulk billing incentives for diagnostic imaging and pathology services; the scrapping of proposed changes to the Medicare Safety Net that would have penalised vulnerable patients; the delaying of the introduction of the Health Care Homes trial until October to allow fine-tuning of the details; the moving to an opt-out approach for participation in the My Health Record; and recognising the importance of diagnostic imaging to clinical decision-making.

The AMA supports the Government’s measures to increase the prescribing of generic medicines, when it is safe and appropriate and discussed with the patient, and preserves doctors’ clinical and prescribing independence, with savings to be invested back into the Pharmaceutical Benefits Scheme.

“We also welcome the Government’s allocation of $350 million to help prevent suicide among war veterans; the expansion of the Supporting Leave for Living Organ Donors Program, which allows donors to claim back out-of-pocket expenses and receive up to nine weeks paid leave while recovering; measures to increase the vaccination rate; and the ban on gambling ads during live sporting broadcasts before 8.30pm,” Dr Gannon said.

Mr Hunt said the Budget delivered on the Government’s commitment to guarantee Medicare and ensure Australia’s health system continues to be one of the best in the world.

“It ensures the essential healthcare services Australians rely on,” the Minister said.

“The 2017-18 Budget includes a $10 billion package to invest in Australia’s health system and the health of Australians.

“The Government will establish a Medicare Guarantee Fund from 1 July 2017 to secure the ongoing funding of the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme, guaranteeing Australians’ access to these services and affordable medicines into the future.”

The Medicare levy will rise by 0.5 percentage points in two years’ time, to help close the funding gap for the National Disability Insurance Scheme.

“This measure will collect $8.2 billion over four years for the NDIS,” said Treasurer Scott Morrison when handing down his Budget.

Shadow Treasurer Chris Bowen said the Government had failed the Medicare test because it had delayed reversing cuts to Medicare for three years.

“Budgets are about choices and Prime Minister Malcolm Turnbull has made his choices tonight,” Mr Bowen said.

“He has chosen multinationals over Medicare. He has chosen big business over battlers.”

Dr Gannon said the Health Budget effectively ends an era of poor co-payment and Medicare freeze policies, and creates an environment for informed and genuine debate about other unfinished business in the health portfolio.

“We now need to shift our attention to gaining positive outcomes for public hospitals, prevention, Indigenous health, mental health, aged care, rural health, private health insurance, palliative care, and the medical workforce,” he said.

“The thaw in the freeze is the beginning, not the end.”

Chris Johnson

[Comment] Palliative care in humanitarian crises: always something to offer

More than 128·6 million people across 33 countries require life-saving humanitarian assistance, 92·8 million of whom are particularly vulnerable.1 Palliative care, however, has been omitted from efforts to tackle humanitarian crises.2 Palliative care is, according to WHO, “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering”.3 We propose holistic palliative care as an integral component of relief strategies.