Policy Debates


Following the outstanding success of our very first grassroots policy development debates ‘from the floor of conference’, the popular Conference delegate policy debates are happening again this year. We asked our local members via the State and Territory AMAs to submit policy debate topics to be discussed by delegates ‘live’ at Conference. Every member can have their say. This is AMA democracy at work. 

The confirmed topics this year include:

Paid family and domestic violence leave

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Intimate partner violence is the leading contributor to the preventable death, disability and illness burden in women aged 15-45[1]. 

The AMA Position Statement Family and Domestic Violence - 2016 notes that:

“The statistics on the deaths and serious injuries resulting from family and domestic violence has been called a national epidemic, and one of Australia’s biggest social, legal and health problems.” [2]

After a victim of family violence is murdered by her partner people often ask “why didn’t she leave?”

Economic insecurity is one of the most significant obstacles confronting victims of family violence who are seeking to leave a violent relationship .” [3] . When victims are leaving a violent relationship they need time and money to physically get away, establish a safe place to live, move their children, establish a safety plan for their personal security, and potentially to attend court hearings. Victims are at greatest risk of homicide at the point of separation and they need resources and time to mitigate this risk and to remove themselves and their children from abuse. 

Providing 10 days of paid domestic violence leave to every employee is estimated to cost the equivalent of five cents per worker per day. Domestic violence already costs workplaces through absenteeism and staff turnover, decreased staff performance and productivity. Domestic violence also costs the community and health system due to the burden of physical and mental illness and disability that it creates. 

Domestic violence leave is available to employees at private companies including Qantas, NAB, Westpac, Telstra, IKEA, Telstra and Woolworths. Ten days of paid domestic violence leave exists in over 1000 enterprise agreements approved under the Fair Work Act in the last two years. Queensland and Western Australia offer 10 days of paid domestic violence leave to public sector employees, while South Australia offers 15 and in Victoria and the Australian Capital Territory 20 days of paid leave is available. Internationally paid domestic violence leave is available to employees in New Zealand, the Philippines and parts of Canada. 

One Australian woman is murdered a week by her partner. One in four Australian women experience family violence and half of the victims have children in their care. If we wish to tackle this national epidemic and address one of Australia’s biggest health problems we need to help women leave abusive situations by making 10 days of paid domestic violence leave the minimum available to all employees. This can be achieved through changes to the National Employment Standards and advocacy for a minimum of 10 days of paid domestic violence leave to be included in all enterprise agreements. 

[1] Victorian Royal Commission into Family Violence, Summary and Recommendations (2016), viewed 26 December 

2018, http://www.rcfv.com.au/MediaLibraries/RCFamilyViolence/Reports/RCFV_Full_Report_Interactive.pdf  

 [2] Australian Medical Association Position Statement Family and Domestic Violence – 2016

 [3] Economic Aspects of Paid Domestic Violence Leave Provisions By Jim Stanford. Centre for Future Work at the Australia Institute December 2016 Accessed 26 December 2018 https://d3n8a8pro7vhmx.cloudfront.net/theausinstitute/pages/1408/attachm...

Draft motion

That our AMA advocate for all employees to have access to a minimum of 10 days of paid domestic violence leave. 

Should all GP registrars be employed under single employer contracts?

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There is potential to explore the practical application of a single employer model for GP registrars to enhance flexibility for GP Registrars with their training terms and in completing their training, including portability of workplace entitlements. GP registrars experience a lack of parity in remuneration compared to their non-GP registrar counterparts and are disadvantaged by an inability to transfer leave and other entitlements as they progress through training.

The National Rural Generalist Pathway (NRGP) has recommended a “duration of training” contract which is essentially a single employer model for the duration of rural generalist training in their region or community. Whilst incentivising training through the NRGP, this creates further inequities in employment conditions for GP registrars not enrolled in the NRGP. 

There is a risk that this will act as a further disincentive for medical graduates to choose a career in general practice.  General practice training was undersubscribed again in 2019 and anecdotal reports suggest that fewer medical students are considering a career in general practice. GP registrars already earn less that their non-GP registrar counterparts and are unable to access continuity in leave arrangements as they move through training.

The failure of GPSA and GPRA to reach an agreement in 2018 on a new National Terms and Conditions for the Employment of Registrars (NTCER) agreement reinforces the fragility of the general practice environment which is under sustained funding pressure. Having no expiry date, the NTCER will continue to operate in its current form. This presents an opportunity to explore alternatives to the NTCER that will deliver equitable employment conditions for GP registrars, while recognising the efforts and commitment of supervisors, especially at a time of significant financial pressures in general practice.

In November 2018, Federal Council approved the following motion:

That Federal Council invites and supports General Practice Registrars Australia (GPRA) and General Practice Supervisors Australia (GPSA) to explore the development of a future employment model, including a funding framework, which ensures:

  1. safe and high-quality GP training
  2. the protection of employment conditions and entitlements for GP Registrars
  3. support for GP Supervisors in accepting the burdens and responsibilities of providing training
  4. and which is overseen and administered by a body independent of the Colleges who will soon be tasked with administering training.

Clearly there is an appetite for change and ultimately GP registrars and supervisors will have to own the solutions which may take some time to sort out. The issue of remuneration and billings reform will be a key challenge as well as continuity of entitlements and access to leave provisions. Additional funding to support reform in this area will be required as the burden of fulfilling all contractual agreements must not lie with general practices employing registrars.

AMA National Conference is asked to consider how employment conditions and working arrangements for GP registrars could be improved to achieve fair and equitable employment conditions that meet the needs of registrars and supervisors alike.

This could include extending the proposed six-year, single employer contracts for rural generalist GP registrars to all GP registrars.

Draft motion

That our AMA recommends the Government develop a single employer model as an alternative to fee for service arrangements to deliver equitable remuneration and employment conditions for GP registrars, and between GP registrars and non-GP registrars, while at the same time meeting the needs of supervising practices.

Alcohol use in pregnancy

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The NHMRC’s Australian Guidelines to Reduce Health Risks from Drinking Alcohol (2009) state that “for women who are pregnant or planning a pregnancy, not drinking is the safest option.” Recent research shows that approximately 60% of women attending antenatal clinics in Sydney and Melbourne have drank alcohol during pregnancy, often at risky levels before pregnancy recognition. 

Because brain growth and development of the foetus occur throughout pregnancy, exposure to alcohol at any stage in a pregnancy can have negative lifelong impacts. These include a suite of cognitive, behavioural, physical and neurodevelopmental outcomes, birth defects and Foetal Alcohol Spectrum Disorder (FASD). 

In Australia, the prevalence of FASD in the general population is unknown, although it is likely to be similar to that of the United States (2-5%). Rates as high as 19% have been documented in some high-risk Indigenous Australian communities. The AMA’s position statement Foetal Alcohol Spectrum Disorder (2016) acknowledges the impact of FASD on Australia’s health, education and justice systems, economy and social fabric.   

Medical professionals, particularly General Practitioners, can play a vital role in the prevention of FASD, through the asking women about their alcohol use,  providing clear and accurate information about potential harms,   assisting women who are pregnant or planning a pregnancy to refrain from drinking alcohol, and referring if necessary to specialist services. However doctors don’t feel confident to raise this topic and patients often receive mixed and confusing messages.

A central recommendation of the AMA’s 2016 Position Statement is that clinicians be appropriately trained to engage in sensitive conversations with patients about their alcohol use and the harms associated with drinking during pregnancy. Medical professionals need to be confident to advise women and their partners from a range of backgrounds, acknowledging the diverse risk factors associated with alcohol use during pregnancy and provide a brief intervention when appropriate. 

There is concern that medical professionals are providing advice that is variable, incorrect, or consistent with previous guidelines, which allowed for one to two standard drinks per week during pregnancy. Therefore, the message that no safe level of alcohol consumption during pregnancy has been established  needs to be reinforced. 

Draft motion 

That the AMA support NHMRC guidelines that clinicians should advise women who are pregnant or planning a pregnancy that the safest option is to avoid alcohol entirely, based on the information that prenatal alcohol exposure may harm the unborn child and that no safe level has been established for alcohol consumption in pregnancy.

Introducing targets for rural research funding and facilities

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The National Health and Medical Research Council (NHMRC) is the largest organisation funding health and medical research in Australia, administering around $943 million of research funding in 2017-18. The majority of this funding is delivered to metropolitan universities and research institutes. There is no dedicated rural research stream.

Even with the proliferation of rural clinical schools and the associated facilities and infrastructure, rural areas still lag behind in the production of clinical and translational research and have many barriers to accessing and conduct clinical trials. For example, many clinical trials in cancer require access to tissue banks/bio banks- infrastructure that almost immediately eliminates rural/regional centres from offering access to new cancer treatments such as melanoma, breast cancer and bowel cancer. 

The Government committed to improving rural health with the Stronger Rural Health Scheme in the 2018/19 budget, however this excluded health and medical research targets. Similarly, the $20 billion Medical Research Future Fund, first announced in 2015, included no specific mention of research to be conducted rurally. 

With almost 30% of Australians now living in non-metropolitan areas, the AMA should consider advocating for improved access to research funds in rural areas to administer more research, fund the development of infrastructure, including facilities capable of running complex clinical trials. 

Requiring the NHMRC to include mandated targets for funding to rural areas in the form of targeted calls, partnerships, or individual research funding would greatly benefit rural communities. More patients could access novel treatments and clinical trials, it would improve engagement of rural clinicians in research/clinical trials while upskilling them, improve the quality of research being undertaken by including more diverse populations, and improve understanding of rural health issues through collaborations.

Draft Motion

That AMA calls on the National Health and Medical Research Council to introduce a rural research funding scheme for health and medical research.

The implications of non-fatal strangulation in family violence

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Intimate partner violence is the leading contributor to ill-health and premature death in women under 45, more than any other well-known risks including high blood pressure, obesity and smoking. [1] 

The occurrence of non-lethal strangulation in domestic and family violence situations is a serious act of violence. It can cause serious psychological and physical harm without any obvious signs on the body [2], it is an indication of increasing severity of violence [3] and it is a significant risk factor for future homicide [4].

A woman surviving non-fatal strangulation is six times more likely to subsequently be subjected to an attempted murder, and seven times more likely to be subsequently murdered by her family violence perpetrator, underscoring the importance of screening. [4]

Non-fatal strangulation can also result in permanent physical disability, in many instances without external signs of injury, and this disability can be incorrectly attributed to other causes. It can cause brain damage, pneumonitis, miscarriage, acute myocardial infarction, injury to the carotid arteries, post traumatic stress disorder, memory loss, depression, anxiety and delayed death that occurs days or weeks after the assault. 

Non-fatal strangulation also affects victims psychologically. It is a potent weapon used to instil fear and increase control over a family violence victim. 

Because injuries from non-fatal strangulation can have no external signs and because of the greatly heightened risk of death at the hands of a perpetrator, it is vital that medical professionals ask women about non-fatal strangulation and be aware of the potential physical injuries that result, and the subsequent risk of murder at the hands of the perpetrator.

Education of professionals and the public can play an important role in addressing the health issue of non-fatal strangulation, so that victims of family violence and their doctors are aware of the risk of death and disability, including permanent brain injury. 

[1] AMA Family Violence Resource, Supporting Patients Experiencing Family Violence; 27 May 2015; URL: https://ama.com.au/article/ama-family-violence-resource accessed 27 December 2018.

[2] Pritchard, AJ, Reckdenwald, A, Nordham, C & Holton, J 2016, ‘Improving Identification of Strangulation Injuries in Domestic Violence: Pilot Data From a Researcher-Practitioner Collaboration’ Feminist Criminology, June 2016, pp 1 – 22. 

[3] Douglas, H & Fitzgerald, R 2014, ‘Strangulation, Domestic Violence and the Legal Response’, Sydney Law Review, vol. 36, pp 231 – 254.

[4] Glass N, Laughon K, Campbell J, Block CR, Hanson G, Sharps PW, Taliaferro E. Non-fatal strangulation is an important risk factor for homicide of women. J Emerg Med. 2008 Oct; 35(3): 329–335

Draft motion

That our AMA promotes awareness of the risks of non-fatal strangulation among medical professionals and includes mention of the risks of non-fatal strangulation in the next iteration of the AMA Policy on Family and Domestic Violence. 

16 per cent of the Federal health budget should be the mandated minimum spend on general practice

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Primary care is regarded as the most cost-effective part of the health system and there is the potential to reduce downstream health costs by improving access to high quality GP-led primary care services. Recent research has shown that individuals in communities with more GPs live longer than those with access to fewer.  

Every year around 88 per cent of Australians see a general practitioner and 80 per cent have a usual GP. 90 per cent of problems encountered in general practice are managed in general practice. Over 90 per cent of patients report that their GP listens to them, spends enough time with them and shows them respect. Despite this, general practice services represent around 7 per cent of total government (including federal, state and territory, and local) health expenditure, or $357 per person. For comparison, $2606 was spent per person on public hospitals.  In 2016-17, only 12.3% of total health expenditure by the Federal Government went to general practice. 

The AMA has called for spending on general practice to be increased to 10 per cent of total health expenditure, however this figure would be at the discretion of future health budgets and require commitments at State and Federal levels.

In 2017, the state of Oregon in the United States passed Senate Bill 934 which required at least 12 per cent of health expenditure to be spent on primary care services by 2023. If Australia were to adopt similar legislation, it would ensure adequate spending on general practice for the next generation.

Increased spending in general practice will lower emergency department presentations and hospital use, decreased hospital re-admission rates, and lead to downstream cost saving for the healthcare system.

A mandated figure of 16 per cent of total Federal health expenditure to be directed to general practice would also improve the confidence of medical professionals in general practice, encouraging more doctors in training to pursue a career in the field.

Draft motion

That AMA lobbies the Federal Governments to increase funding for general practice so that it represents at least 16 per cent of total health spending, and that this figure be mandated. 

 

Credentialed pharmacists in rural and remote areas

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Credentialed pharmacists are currently limited to performing 20 medication management reviews (MMRs) per month. This is adequate in urban settings, however it disadvantages rural areas where there may be no access to credentialled pharmacists.

Doctors do not use MMRs in rural areas, not because they do not wish to, but as the local pharmacist has to contract a pharmacist who can perform MMRs, it is not financially viable to get a Pharmacist to come to a rural or remote area, pay transport fees, accommodation and meal fees, and then perform only 20 MMRs. 

For example, there is a town with over 380 patients who are eligible for MMRs. At 20 a month, this will take 19 months if there is a pharmacist who thinks that it is financially viable. 

By removing the limit in Modified Monash Model areas 4-7, this would create an environment where a pharmacist can visit a town and perform all or some of the services. 

It is important to note that this would be part of a doctor-led team and must be performed collaboratively.

Draft motion

That AMA advocates for the removal of the limit of 20 Medication Management Reviews per month credentialled pharmacists are able to perform in Modified Monash Model 4-7 to improve patient care and reduce adverse medication events.