Policy topics to be debated at National Conference


In response to the comments of delegates in previous years, and in the interests of making National Conference a forum for debate on issues of relevance to AMA members, in 2018 a new format will be introduced on day two of the Conference with debate on policy resolutions that have been put forward by Councils and Committees of Federal Council, and State AMA Councils. These motions on notice were received within the time period permitted under National Conference Standing Order 4.3 for Notice of Motions. 

The motions and supporting background have been circulated in advance for delegates to consider. Debate on day two will be governed by the rules of debate set out in the Standing Orders of National Conference. These have been amended in 2018 to specify that debate can run for no more than 30 minutes on any one topic. All delegates, both appointed and member delegates, may participate in the debate on motions, and vote on the resolutions.

Resolutions of National Conference are advisory only and any resolution adopted by delegates will be submitted to Federal Council for formal adoption and implementation.

1. Funding general practice to reduce hospitalisation

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Hospitals are funding on the basis of activity, with no real systemic incentive to engage with primary care in order to keep people out of hospital. 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.

According to the My Health Communities Web update, in 2015-16 there were nearly 680,000 hospitalisations for conditions for which hospitalisation is considered potentially preventable. This represented 6% of all hospital admissions to a public or private hospital in Australia that year 1.

Furthermore, AIHW data indicates readmissions to public hospital after surgery for the most part sit at around 20 per 1000 separations 2

Reducing these could be achieved through better integration between hospitals and primary care, including improved discharge planning and the capacity for hospitals or Local Health Networks to fund targeted interventions in general practice aimed at improved coordination of care and capacity building. 

Traditionally, the responsibility for the delivery of hospital services lies with the states and territories, whereas the responsibility for funding primary care services largely falls to the Commonwealth. The AMA does not have any policy in relation to public hospitals or Local Health Networks being funded to support primary care interventions, although the AMA and states AMAs have engaged positively in trial programs where they exist such as in NSW.

Moved by: Dr Richard Kidd
Seconded by: Dr Shaun Rudd

Draft Motion

That our AMA develops policy that encourages Local Hospital Networks to fund targeted GP led primary care services designed to reduce preventable hospital admissions and re-admissions.

 

1https://www.myhealthycommunities.gov.au/our-reports/potentially-preventa...

2Australian Institute of Health and Welfare. 2017. Admitted patient care 2015-16: Australian Hospital Statistics. Health Services Series no 75. Cat. No. HSE 185. Canberra: AIHW p 239

2. Booking Fees

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It is believed the overwhelming majority of medical practitioners bill appropriately, however there are known instances of problematic billing practices being used.  It is not known whether these practices are increasing and whether these behaviours are linked to the lack of indexation of the MBS and PHI benefit schedules.  

There are three main issues:

  1. Splitting of fees by surgeons with either assistant surgeons or anaesthetists.
  2. Splitting of fees by surgeons (surgeon invoices the private health insurer and the patient separately for the one procedure).
  3. Overcharging/excessing charging.

APRA statistics state that around 89% of privately insured medical services are charged at no-gap by the doctor - which means that the doctor accepts the fee level set by the patient's private health insurer.  A further 6% are charged under ‘known’ gap arrangements.  The AMA has always argued that this means that roughly 5% of privately insured patients may be charged fees that exceed private health insurance levels.  

However, the accuracy of this statistic depends on the quantum of splitting of bills and ‘administrative’ billing that occurs. If there is a considerable increase in ‘administrative’ or split bills, these statistics will become meaningless.

While it is believed the majority of the profession bills appropriately, the impact of the minority of those who split bills or issue booking fees have a resounding negative impact on medical professional integrity. These practices also undermine the value of private health insurance as consumers assume that they will incur an out-of-pocket expense. The result being that a sizeable proportion of patients either delay obtaining care 1.  

In 2017 the AMA Federal Council approved the revised position statement on Setting Medical Fees and Billing practices, to include statements condemning booking fees, split billing and billing for non-itemized services: 

1.4 … The AMA does not support exorbitant charges; fees that the majority of a practitioner’s peers would consider to be unacceptable. 

1.6 All professional medical services provided should be billed, itemised and described with the applicable MBS item or the AMA List of Services and Fees (AMA List) item, for relevant services where there is no corresponding MBS item.

1.7 If a medical practitioner has signed a contract with a private health insurer, the billing requirements must be adhered to.  Circumventing contractual arrangements by issuing a second, separate bill for a single course of treatment is inappropriate.

Noting the work of the Ministerial Advisory Committee on Out of Pocket Costs is underway, the profession needs to be on the front foot with policy lines condemning booking fees and split billing

Moved by: Dr Brad Horsburgh
Seconded by: A/Prof Julian Rait

Draft Motion

That our AMA:

  1. Considers the reputational impact that ‘booking fees’ and split bills have on the wider medical profession;
  2. Considers a campaign to publicly denounce inappropriate billing practices and in particular, booking fees;
  3. Endorses appropriate billing practices to be where medical services are linked to itemized fee schedules, such as the MBS or AMA Fees List;
  4. Notes that RACS has previously written to the AMA in 2017 seeking the AMA’s support in making a more explicit statement on fee splitting; and
  5. Notes the revised 2017 AMA position statement on Setting Medical Fees and Billing Practices.

 

1See Community Affairs References Committee (2014) Out-of-pocket costs in Australian Healthcare, pp32–36

3. Should we be quarantining training places for Rural Medical Generalists?

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The Government announced its commitment to establish a National Rural Health Commissioner (the commissioner) during the 2016 Federal Election. Professor Paul Worley was appointed to the position and will be responsible for developing a National Rural Generalist Pathway (NRGP).

The aim of the pathway will be to address the lack of access to training for rural generalists, and to improve the supply of health professionals in regional, rural and remote Australia. The commissioner will also provide advice as required to the Minister responsible for rural health and rural health reform.

Quarantining procedural training places

Consideration of the design of the NRGP should include the merits or otherwise of quarantining training places for trainees on the pathway, with these being perceived as an essential feature of the Queensland Rural Generalist Pathway.

The AMA has previously opposed quarantining of procedural training places for advanced rural pathway trainees because of concerns that general practitioner (GP) registrars outside the pathway who are committed to rural practice may find it difficult to get procedural training experience. This could be divisive and discourage some GP registrars from pursuing a long-term career as a rural generalist.

Quarantining procedural training posts for rural generalists may also be at the expense of other specialist trainees, and colleges who require those positions for their own trainees. Apart from the Commonwealth’s Specialist Training Program (STP), non GP specialist training posts are the responsibility of jurisdictions, and employers such as hospitals may also reluctant to set aside posts where such decisions may be perceived as interfering with their capacity for service delivery.

Our view until now has been that the solution does not lie with quarantining places, but ensuring more resources are devoted to providing enough procedural training places commensurate with anticipated community need; any discussion on quarantining places should be held over until this is goal is achieved.

However rural medical workforce shortages persist, with any improvements in rural workforce numbers largely the result of the recruitment of IMGs. This is not a sustainable model and, based on the Queensland experience, the development of an NRGP may help to address this situation.

Access to training posts will be a critical element of any successful NRGP model. This may include extending the NRGP beyond general practice training posts to include general specialists as part of efforts to help ensure that Australia can build a sustainable generalist workforce that meets the needs of rural communities. In this context, it is reasonable for the AMA to re-evaluate its opposition to quarantined training places based on the Queensland experience and to ensure that it strikes the right policy balance, including the extent to which it is meeting the needs of rural communities.

Moved by: Dr John Zorbas
Seconded by: Dr Peter Maguire

Draft Motion 

That our AMA calls on the Commonwealth and state/territory Governments to fund sufficient additional training posts required to meet the needs of the NRGP and agrees that these should be quarantined for the NRGP.

4. e-cigarettes as a harm reduction measure

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Seventy per cent of people with schizophrenia and 61 per cent of people with bipolar disorder are smokers, compared to 16 per cent of those without mental health problems. Indigenous Australian have similarly high rates. The Royal Australian & New Zealand College of Psychiatrists have called for the controlled introduction of e-cigarettes as a harm reduction measure and this approach is similar to policy in Great Britain and Canada. 

According to the latest evidence commissioned for Public Health England in 2018, e-cigarettes pose only a small fraction of the risk of smoking, and encouraging smokers to switch completely to vaping would produce substantial health benefits.1  The review, an update of Public Health England’s 2015 review, found no evidence that e-cigarettes were a route into smoking among young people, and that e-cigarettes do not seem to be undermining the UK’s long term decline in cigarette smoking among young people. 

The report recommends that health professionals and stop smoking clinics should provide behavioural support to smokers who want to use an e-cigarette for smoking cessation. A training course on e-cigarettes for healthcare professionals by the National Centre for Smoking Cessation and Training is now available.2

The position of Public Health England is that e-cigarettes should be regulated as medicines through the Medicines Healthcare Products Regulatory Agency. 

Moved by: A/Prof Steve Kisely
Seconded by: Dr Gary Galambos

Draft Motion

That our AMA:

  1. Notes that current tobacco control measures have not changed the high rates of smoking in marginalised populations such as people with severe mental illness or Indigenous Australians; and
  2. Supports the controlled introduction of e-cigarettes as a harm reduction measure.

 

1 McNeill A, Brose LS, Calder R, et al. Evidence review of e-cigarettes and heated tobacco products: a report commissioned by Public Health England. 6 Feb 2018. https://www.gov.uk/government/publications/e-cigarettes-and-heated-tobacco-products-evidence-review

2 National Centre for Smoking Cessation and Training. Electronic cigarettes: a briefing for stop smoking services. 2016. www.ncsct.co.uk/publication_electronic_cigarette_briefing.php.

5. Doctors dispensing pharmaceutical or other therapeutic products

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The AMA’s Ethics and Medico-Legal Committee (EMLC) is currently reviewing the Position Statement on Medical Practitioners’ Relationships with Industry 2012 as part of the routine, five year policy review cycle. 

Current AMA policy advises that doctors should not dispense pharmaceuticals or other therapeutic products unless there is no reasonable alternative. Prior to 2010, the AMA advocated that doctors should not dispense pharmaceuticals or other therapeutic products for material gain unless there is no reasonable alternative. In 2010, the words ‘for material gain’ were removed from the policy, opening the way for it to be acceptable for doctors to make a profit from dispensing.

The EMLC believes this particular position places doctors in an (actual or perceived) conflict of interest and recommends that the AMA return to the former position that doctors should not dispense pharmaceuticals or other therapeutic products for material gain unless there is no reasonable alternative available. By reinstating that doctors should not dispense ‘for material gain’, it removes the perception (and any incentive) that doctors profit from prescribing or recommending therapeutic products to patients (a clear conflict of interest). For the purposes of the policy, ‘material gain’ refers to making a profit over and above ‘recovery costs’ such as the cost of purchasing, storing and disposing of the products. 

Importantly, the current version of the AMA’s policy continues to recognise that practising doctors who also have a financial interest in dispensing and selling these products are in a prima facie position of conflict of interest. This particular position has not changed from 2002. 

Conflicts of interest in medicine have the potential to undermine public trust and confidence in the profession if not managed appropriately. The community trusts doctors to prescribe or recommend pharmaceutical and other therapeutic products based on patients’ health needs and not doctors’ own financial interests. The AMA has made a serious commitment to developing and promoting policies and guidelines highlighting the need for doctors to appropriately manage conflicts of interest in medicine. Advocating that doctors should not dispense therapeutic products ‘for material gain’ is consistent with this advocacy.

Current AMA policy 

Excerpt from Position Statement on Medical Practitioners Relationships with Industry 2012

11.1 Practising doctors who also have a financial interest in dispensing and selling pharmaceuticals or who offer their patients health-care related or other products are in a prima facie position of conflict of interest;

11.2 Doctors should not dispense pharmaceuticals or other therapeutic products unless there is no reasonable alternative. Where dispensing does occur, it should be undertaken with care and consideration of the patient’s circumstances.

Former (now superseded) AMA policies

Excerpt from Position Statement on Doctors’ Relationships with the Pharmaceutical Industry 2002

10.1 Practising doctors who also have a financial interest in dispensing pharmaceuticals or who offer their patients health-care related services or products outside the normal function of a doctor are in a prima facie position of conflict of interest. The Association therefore recommends that:

10.2 Doctors should not dispense pharmaceuticals, etc. for material gain unless there is no reasonable alternative. 

Excerpt from Position Statement on Doctors’ Relationships with Industry 2010

8.1 Practising doctors who also have a financial interest in dispensing and selling pharmaceuticals or who offer their patients health-care related or other products are in a prima facie position of conflict of interest. 

8.2 Doctors should not dispense pharmaceuticals or other therapeutic products unless there is no reasonable alternative. Where dispensing does occur, it should be undertaken with care and consideration of the patient’s circumstances.

Moved by: Dr Chris Moy
Seconded by: Dr Helen McArdle

Draft Motion

That our AMA supports the position that doctors should not dispense pharmaceutical or other therapeutic products unless there is no reasonable alternative and, where dispensing does occur, it should not be undertaken for material gain.

6. Supporting implementation of quality initiatives through entrenching the role of the profession and guaranteeing adequate funding

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The COAG Heads of Agreement – public hospital funding to 2020 provides for the States to implement a variety of new quality initiatives intended to reduce the number of avoidable admissions/readmissions and reform pricing mechanisms to not reward unnecessary/unsafe care.

The Commonwealth’s public hospital funding arrangement is subject to data driven “risk adjustment” or penalties where self-reporting shows:

  • Avoidable sentinel events = Zero funding is available for the activity.
  • Hospital acquired complications = Depending on the presentation / character of the patient, a decrease in the activity’s funding or penalty (i.e. substantial) reductions are applied.  This is intended to improve public hospital systems, for example, infection control.
  • Avoidable readmissions = Subject to funding cuts.  This is intended as incentive to better manage after care, improve discharge and better integrate care.

There is willingness to improve patient outcomes, reduce preventable poor quality patient care, better coordination care across the boundary of admitted/non-admitted care – especially for patients with one or more chronic conditions.  However, sustainable quality initiatives are complex and costly requiring proper resourcing and well managed, doctor led, engagement to successfully implement.

Rather than via penalty based regimes, COAG’s improvement targets require the time, staffing and funding to build organisational capacity.  Penalties are a false premise incentive in that they imply doctors exercise a choice to not lower complication rates.  Instead, we know patient outcomes are optimised when medical practice is supported, given appropriate resourcing (funding and staff) and is directly engaged in implementation and review decisions.

Where COAG targets are not met, funding cuts will result but the targets remain.  This has perverse potential to establish a downward spiral of ‘doing more with less’ and incentivises rapid, ‘knee jerk’, inefficient and unmanaged change.  Further, a penalty regime must not act as incentive to ‘cloak’ less optimal outcomes through its inherent disclosure / funding reduction relationship and must instead encourage systems & quality practice review and improvement.

The COAG approach is data driven thus requiring the time & the funding for new infrastructure, the designing of agreed collection methodologies, the linking of primary & tertiary data and the establishment of nationally consistent primary healthcare data definitions. 

Change to work practice will be necessary (for example: 24/7 model of care availability).

This means fair and funded redesign of industrial entitlements to ensure: 

  • appropriate EFT staffing levels,
  • proper remuneration;
  • restrictions on excessive / fatigue generating workloads;
  • preventing potential for administrative support and/or clinical support time being redirected to assist data analysis, design of new systems, and/or implementing process change; and
  • collaborative decision making enshrining clinical lead.

Moved by: Dr Roderick McRae
Seconded by: Dr Stuart Day

Draft Motion

That our AMA calls on all Australian jurisdictions to recognise that enabling clinical lead and providing adequate time & resources is the means to both improve public hospital performance and to ensure attention is not diverted from high value care initiatives.

7. Is prevocational research worth the (CV) paper it’s written on?

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Entry requirements for vocational training commonly take into account a range of academic and vocational considerations, and in some instances, clinical and research pre-requisites.

AMA policy on entry requirements for vocational training does not support pre-requisites that are unnecessarily onerous and/or extraneous to beginning practice as a vocational trainee, particularly those that are hidden or implicit, or are of high cost but not required by trainees for selection. 1

Yet in an environment where there is unprecedented competition for access to specialty training places, and an excess of medical graduates entering into the medical training bottle neck, trainees are feeling increasing pressure to undertake activities that will enhance their CVs for application process for College training programs. In particular, a point of distinction (often rated highly by selection processes) has become academic achievements e.g. published articles or higher degrees e.g. masters degrees.

The AMA supports pathways that encourage clinical academic practice 2.  Participation in research enables doctors to evaluate their practice objectively, think critically about a situation and to be involved in advancing their discipline. 

However, should completion of a discrete piece of research or undertaking of a higher degree be weighted more highly in selection processes than clinical experience? The authors of this motion feel that colleges should be doing more to recognise unaccredited service jobs in other specialties, on the basis that a well-rounded doctor is arguably more beneficial to one’s own specialty practice.

There is a view that the trend toward ‘CV buffering’ is driving ‘a CV arms race where a Masters Degree is rapidly becoming a necessity, not a standout’, and that this is placing significant and unnecessary financial and personal stress on doctors in training. With patients increasingly suffering from multiple conditions and with a growing emphasis on team-based care, it is clear that practice in each medical specialty benefits from clinical experience in other specialty areas. 

However, the emphasis on research and higher degrees in College selection processes, as well as a tendency for Colleges to focus on trainee experience in their own specialty areas, could be seen as potentially discouraging trainees from seeking well-rounded clinical experience. 

There is a view that Colleges should do more to ensure their future vocational trainees prioritise working in clinical roles in trainees’ prevocational years, including in other specialties, prior to entering vocational training. 

The AMA National Conference is asked to consider whether greater weighting should be given to the breadth and length of early postgraduate clinical experience, including work in other specialty disciplines, as opposed to research experience and higher degrees in the grading of applications for selection into vocational training.

Moved by: Dr John Zorbas
Seconded by: Dr Chris Wilson

Draft Motion

That our AMA calls on the learned Colleges to:

  1. Ensure appropriate emphasis is placed on the importance of broad experience in a variety of clinical fields for selection into vocational training, and
  2. Correct the current overemphasis on non-clinical qualifications and courses which is to the detriment of well-rounded trainees.

 

1 AMA Position Statement on Entry requirements for vocational training – 2014 https://ama.com.au/position-statement/entryrequirements-vocational-train...

2 AMA Position Statement on Clinical academic pathways in medicine – 2013 https://ama.com.au/position-statement/clinicalacademic-pathways-medicine...

8. Gender equity

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The AMA’s position statement ‘Sexual harassment in the medical workplace – 2015’ recommends that the healthcare system:

  • Promote the intentional inclusion of women in the medical workforce, including achieving gender balance in senior roles and strengthening women in medicine mentoring programs.
  • Ensure all doctors are able to fully participate in the medical workforce and are guaranteed access to a range of flexible employment, return to work and training opportunities.

While this policy presents a system we strive to achieve, it lacks practical suggestions on how to attain these goals.

The AMA needs to address gender equity with specific attention to systemic factors that undermine it.

Inequitable parental leave, inflexible training, short contracts for Doctors-in-Training, the way parental leave is paid (which creates a challenge for small departments), and a lack of access to childcare especially with increasing demands of consultant shift work are all issues which contribute to gender inequity.

Moved by: Dr Tessa Kennedy, Chair, AMA (NSW) Council of Doctors in Training
Seconded by: Prof Brad Frankum

Draft Motion

That, noting the AMA position statement on Sexual harassment in the medical workforce – 2015, our AMA establishes practical recommendations that could be implemented into the healthcare system to address the underlying systemic factors that impede the health system’s ability to adequately address gender equality.

 

9. The role of GPs in providing long-term healthcare

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The AMA’s position statement on General Practice in Primary Health Care examines the role of general practice in the delivery of primary health care services in Australia and it is a vision for general practice and primary care into the future.

The position statement recognises that “there is significant scope to build on the blended funding arrangements, particularly in tackling chronic and complex disease, which requires comprehensive, integrated and well-coordinated care. A blended model may include practice and service incentives, funding for preventive health care or enhanced care for chronic disease patients, infrastructure grants, and quality improvement measures.”

Further investigation into the role of GPs, and in particular how Medicare could be redesigned to recognise and support the central role of GPs in providing long-term healthcare, rather than short-term medical activity is warranted.

Further to that, the AMA could review and discuss the perverse incentives in the way the Government pays for care, and how in addressing these incentives it could further support long term system sustainability.

Moved by: Dr Ross Kerridge, Councillor, AMA (NSW)
Seconded by: Dr Michael Bonning, Councillor, AMA (NSW)

Draft Motion

That, noting the AMA’s Position Statement on General Practice in Primary Health Care, our AMA should:

  1. Further investigate how Medicare could be redesigned to support the central of role of GPs in providing long-term healthcare; and
  2. Examine the current incentives in payment for care and how addressing these incentives could further support long-term system sustainability.

10. Do we need to take a stronger stand to stop discrimination in recruitment, employment and flexible work practices?

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While various state and federal laws make it unlawful to discriminate against any person on the basis of characteristics such as sex, relationship status, family responsibilities, pregnancy or potential pregnancy or breastfeeding, doctors continue to report to the AMA that they are experiencing workplace pregnancy and carer-related discrimination. 

Last year the AMA received reports from doctors that they were being asked about their family plans during job interviews at public hospitals. This practice was quickly condemned by the AMA who called for equal opportunity in interview, employment and training practices, and an end to discrimination in the medical workforce.1 

Despite a commitment from the profession and workplaces to act on discrimination, in practice a range of cultural, systemic and other factors remain a significant barrier to the equal consideration and treatment of doctors with either actual or supposed family responsibilities in medical workplaces.

The Australian Human Rights Commission Supporting Working Parents: Pregnancy and Return to Work National Review2  (the National Review) found that one in two (49%) women in Australia reported experiencing discrimination in the workplace during their pregnancy, parental leave or on return to work. Further, over a quarter (27%) of the fathers and partners surveyed reported experiencing discrimination related to parental leave and return to work despite taking very short periods of leave.

The National Review’s recommendations identify key strategies and actions for:

  • addressing the high prevalence of discrimination;
  • strengthening the adequacy of existing laws, policies, procedures and practices;
  • promoting leading approaches; and
  • identifying focus areas for further monitoring, evaluation and research.

The AMA supports equal opportunity in the medical workforce3 and flexibility in medical work and training practices.4  There is an opportunity for employers, medical associations, the learned colleges, and members of the profession to work together proactively to change workplace practice and culture to ensure that recruitment is carried out in a fair and transparent manner and that discriminatory questions and practices are eradicated from employment and training processes. 

The AMA is asked to consider its support for the following key actions to strengthen the implementation of legal obligations in relation to pregnancy, parental leave and return to work, and the development of  strategies to drive cultural change within the profession and workplace in support of equal participation across gender in the medical workforce:

“That employers, medical associations, the learned colleges, and members of the medical profession commit to:

  • developing and distributing clear, comprehensive and consistent information about employer obligations, employee rights and leading practices and strategies in relation to pregnancy, parental leave and return to work
  • identifying and removing harmful stereotypes, practices and behaviours about pregnant women and working parents to eliminate discrimination related to pregnancy, parental leave and return to work.”

Moved by: Dr Tessa Kennedy
Seconded by: Dr Jill Tomlinson

Draft Motion

That our AMA:

  1. Reiterates its support for equal opportunity in the medical workforce, and 
  2. Calls on employers, medical associations, the learned colleges, and members of the profession to commit to:
    a. Developing and disseminating clear, comprehensive and consistent information about employer obligations, employee rights and leading practices and strategies in relation to pregnancy, parental leave and return to work
    b. Identifying and removing harmful stereotypes, practices and behaviours about pregnant women and working parents to eliminate discrimination related to pregnancy, parental leave and return to work.

 

Visentin L. Female doctors asked about family plans during job interviews, AMA says. Sydney Morning Herald 2017 2 Jul. https://www.smh.com.au/national/nsw/female-doctors-asked-about-family-plans-during-job-interviews-ama-says-20170702-gx2uop.html

Australian Human Rights Commission. Supporting Working Parents: Pregnancy and Return to Work National Review AHRC 2014 http://www.humanrights.gov.au/our-work/sex-discrimination/publications/headline-prevalence-data-national-review-discrimination

AMA Position on Equal Opportunity in the Medical Workforce – 2016 https://ama.com.au/position-statement/equal-opportunity-medical-workforce-2016

AMA Position Statement on Flexibility in Medical Work and Training Practices - 2005. Revised 2015 https://ama.com.au/position-statement/flexibility-medical-work-and-training-practices

11. Environmental sustainability in healthcare

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As noted in the AMA’s Position Statement on climate change, “human health is ultimately dependent on the health of the planet and its ecosystem”.

This policy also indicates, “mitigation of climate change will be necessary in Australia in order to prevent the adverse health impacts of climate change… Thus strategies that focus on improving energy and combustion efficiency, transitioning to non- combustion energy sources, and promoting active transport have the mutual benefit of reducing GHG emissions and the disease burden from air pollution in Australia. Associated health savings may substantially offset the cost of policy implementation.”

The AMA has an opportunity to build on this policy by supporting a move in healthcare to implement the type of sustainability measures that have already been embraced by other industries and big companies.

Approximately 7% of all greenhouse gases are generated by healthcare and there are many measures (such as practical, consistent recycling programs and power saving lights and computers) that could easily be implemented to reduce this footprint.

Moved by: Dr Tessa Kennedy, Chair, AMA (NSW) Council of Doctors in Training
Seconded by: Prof Brad Frankum

Draft Motion

That noting its current position statement on Climate Change and Human Health, our AMA supports further investigation into environmental sustainability measures that could be incorporated into healthcare across Australia.

12. A Survey of Member Attitudes to Limited Registration and Transition to Retirement

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In 2011 the AMA declined to continue its support of retired doctors’ efforts to maintain limited registration and indicated that it would “not continue to advocate for a registration category for retired doctors solely on the basis that these doctors would be writing prescriptions and referrals for themselves, their family and friends” (Pesce, 2011).

Since 2011 the landscape has changed considerably in terms of the scope of practice of a range of health professions. Government initiatives now enable prescribing rights for allied health practitioners and the expansion of the scope of practice for a range of non-medical health practitioners to include medical advice, referrals for MRI (audiologists), and blood profiles (dietitians) (Ministerial Taskforce on health practitioner expanded scope of practice, Queensland, December, 2016). Physiotherapists, for example, have been given rights “to prescribe scheduled medicines for the management of pain in patients presenting with musculoskeletal and/or spinal conditions to emergency departments or specialist outpatients screening clinics” with the Ministerial report documenting that the “initiative supported and enabled trained physiotherapists to provide advice, prescribe or administer from an agreed list of scheduled medicines under a research framework, subsequent to local credentialing and following approval under Section 18 of the Health (Drugs and Poisons) Regulation 1996”. 

Given the abolition of the Limited Registration Public Interest Occasional Practice (LRPIOP) for retired doctors, and the continuing expansion of scope of practice for allied health professionals, it is timely for the AMA to reconsider and address how senior/retiring doctors can continue to contribute to the profession with their wealth of experience and skills. Indeed Pesce (AMA President, 2011) stated “There are many reasons why doctors of any age, at any time in their lives, may choose to undertake a limited scope of practice.  The challenge for the profession now is to be clear about what those limited scopes of practice might be, and what the appropriate registration requirements should be in terms of continuing professional development and medical indemnity insurance…. I welcome your views on how the AMA can shape the future practice of medicine as individuals make choices about how they practise their craft.” 

Cognisant of these issues, the executive of the Redcliffe and District Medical Association (RDMA) conducted a survey of RDMA, Sunshine Coast LMA, and Northside LMA members (131 respondents) to determine attitudes towards loss of privileges at retirement and the concept of limited or step-down registration. The results (to be reported in the February RDMA newsletter) indicate that the vast majority of survey respondents (88%) agreed that ‘limited registration in retirement’ should be considered and that referral to specialists (79%), pathology (73%) and radiology (72%), and prescription rights (73% ongoing, 60% new and repeat) should be preserved. That 75% of respondents were yet to retire indicates that these issues resonate with a broader membership than retired doctors. Importantly, respondents acknowledged that ‘limited registration’ should carry with it maintenance of standards and competency through continuing professional development. Seventy-one percent of respondents were concerned by the loss of registration privileges, with comments indicating a desire to continue contributing expertise and experience alongside a frustration at how this can be achieved. The results suggest that the issues for practitioners are complex and encompass more than “writing prescriptions and referrals for themselves, their family and friends”. Professional organisations play a role in supporting their members through a number of transitions and these results suggest that the AMA could play a leadership role in facilitating the transitional process for members. 

While retired doctors can maintain full registration by completing the associated requirements of recency of practice, CPD and medical indemnity insurance, there appear to be a number of barriers to retired doctors achieving these. For example, a retired General Practitioner having readily met their recency of practice requirements before retirement may find that accessing direct clinical experience (as their preferred practice under the AHPRA definition of practice) is difficult post-retirement because there are few formal mechanisms to enable this. In other professions mechanisms exist to enable retired professionals to contribute their expertise and maintain practice recency. For example, retired lawyers in Australia are being actively encouraged to take on pro bono work in the community with free practising certificates issued by state law societies as a consequence of advocacy and recommendations contained in the Productivity Commission’s Access to Justice Arrangements Inquiry Report (Engaging Retired and Career-Break Lawyers in Pro Bono, National Pro Bono Resource Centre, February 2010; http://www.probonocentre.org.au/apbn/nov-2015/ free-volunteer-practising-certificates-now-available-five-jurisdictions). Similarly, medical practitioners in a transition to retirement or retirement phase could be invited to fulfil the acute pain management role in emergency departments that is now being transferred to physiotherapists (see above). Retired doctors might also be called upon to oversee diabetes management in pharmacies.  

Little is known about the extent to which retired, registered doctors participate in unpaid/voluntary work nor whether this work is recorded as fulfilling recency of practice requirements nor whether other retired doctors would welcome these opportunities if offered. Additionally, little discussion has centred on how a step-down approach to registration could be achieved and what this might entail. Nor has the AMA membership been surveyed for their views on issues around recency, definition of practice and CPD requirements in relation to retirement, nor on the possible components of a limited or step-down registration. Little is known about the barriers to meeting registration requirements once retired and whether formal mechanisms and supports (such as LMAs providing assistance in the form of journal clubs and MDT meetings for case study discussion) would assist members to achieve these requirements. All professions undergo a process of evolution and future medical practice is likely to incorporate a range of forms of practice. The challenge is for regulatory and professional bodies to acknowledge, support and respond to the dynamic nature of these forms. It is proposed that a comprehensive survey at a national level be conducted to ascertain members’ views on these issues.

Moved by: A/Prof Geoffrey Hawson
Seconded by: Dr Kimberley Bondeson, President, RDMA

Draft Motion

That our AMA undertakes a nationwide survey of members to ascertain their views on limited registration in transition to retirement and retirement, the scope of practice for limited registration, the registration requirements (recency of practice, definition of practice, CPD), and the potential range of practitioner contributions to the profession in transition to retirement and retirement.

13. Healthcare efficacy and efficiency

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The health budget is currently unsustainable.  Australian doctors as custodians of the health system have an important responsibility to ensure every health dollar is spent wisely.

Medical practitioners as stewards of clinical decision-making should acknowledge that to date the sickest have been the first treated. However, the sickest may not be the neediest, nor give the best return for effort.

If the health budget cannot be increased we will be obliged to rationalise resources in some way, either by restricting levels of care, restricting who gets the care, or imposing a patient cost.  All these options could be achieved, but the reality of this situation must first be acknowledged by the AMA.

Moved by: Dr John Cox
Seconded by: TBC

Draft Motion

That our AMA notes:

  1. The limits of the health budget; and
  2. The need for health practitioners to ration care according to relative value for effort. 

14. Access to the National Disability Insurance Scheme for people with psychosocial disability

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The AMA’s position statement on mental health noted that mental health and psychiatric care are grossly underfunded when compared to physical health.  The statement highlighted that well-coordinated and properly funded community–managed mental health services for people with psychosocial disability will reduce the need for hospital admissions and re–admissions, and has the potential capacity to diminish the severity of illness and its consequences over time.

The NDIS is an insurance-based scheme that replaces block funding previously used to support NGOs looking after people with mental illness. It is therefore person based although it is recognised that contract funding may eventually be required for some services for people with psychosocial disability.

Many mental health programmes including Partners in Recovery (PiR), Day to Day Living (D2DL) and Personal Helpers and Mentors (PhaMs) are being rolled into the NDIS. This means funding that was in the 'community' for day-to-day supports and psychosocial services is now with the NDIS.  However, There have been concerns about how the scheme has been applied to people with mental illness including the following issues:

  1. The role of medical practitioners (especially GPs and psychiatrists) in providing NDIS assessments; the recognition of medical diagnoses, and the time   needed by practitioners to provide these assessments.
  2. Access to appropriate medical and psychosocial supports for people with mental illness, including for those deemed ineligible for NDIS packages.
  3. Aboriginal and Torres Strait Islander people and those from culturally and linguistically diverse (CALD) communities and their specific problems with assessments and access.

Moved by: A/Prof Steve Kisely
Seconded by: Dr Gary Galambos

Draft Motion

That our AMA: 

  1. Supports access by people with a mental illness to NDIS assessors with appropriate skills in psychosocial disability and cultural awareness, and
  2. Calls on the NDIA to ensure that psychosocial disability is given the same weight as physical disability for the same degree of functional impairment

15. AMA schedule of recommended fees

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An important emerging issue is the decreasing relevance of the Medicare schedule fee as a way to judge appropriate remuneration for services. National Conference should discuss and support AMA allocating the necessary funds to put out a transparent, meaningful and defensible schedule of fees which has indexation embedded FIRMLY within it for us to widely distribute to government, insurers, providers and the public.

The doctor’s fees resulting in out of pocket expenses for patients, should not be blamed for inadequate funding by government or health funds.

This issue affects GPs, private practice specialists and increasingly, public hospital doctors also.  More public hospitals are transferring the cost of investigations (both pathology and imaging) to the federally funded system, telling public patients it will just be faster if   they have their bloods and scans done in private sector before coming to the hospital outpatients department.  In gynaecology in Brisbane the 2 largest public hospitals won’t accept a referral for public outpatients UNLESS bloods and scans are ALREADY done!!!

This blatant cost shifting means that in effect the states are getting paid for work they are not doing and the federal government is paying TWICE. 

We will never get state governments to fund public hospitals appropriately while this rort can continue, and those in the private sector simply can’t continue to fund quality services at a bulk billing rate (which is what patients want and are repeatedly told by government to expect) when there is NO indexation to the real cost of providing services and has been frozen in the case of pathology and imaging for 20 years!!!.

Various nefarious attempts to eliminate out of pocket expenses have been created and the net effect will be a version of managed care where government (via Medicare schedules) and PHI via (PHI schedules) will dictate what providers will be paid to provide services.  The medical work force is irreversibly changed, with a worsening maldistribution leading to dangerous oversupply in eastern capitals and an unacceptable undersupply in less urban areas.

The newer workforce does not want to run a small business, but rather likes the idea of a paid wage for their labour without the ever increasing compliance demands made upon self-employed doctors. The environment is set for a “new” model of health care delivery and I’m afraid managed care with its many known flaws will flourish unless we make a stand, defend the fee for service principle, force funders to index the rebates they offer patients and allow doctors to practice independently and sufficiently remunerated to allow quality practice with enough “fat” in the system to ensure prevention and chronic care affordable and available rather than just offering “an ambulance at the bottom of the cliff.

Moved by: Dr Gino Pecoraro
Seconded by: A/Prof Julian Rait

Draft Motion

That our AMA:

  1. Fund the development and maintenance of a reworked AMA schedule of fees with ongoing indexation firmly embedded in it, that is transparent, meaningful and defensible; and
  2. Consider wide distribution to government, insurers, providers and the public of the reworked AMA schedule of fees so it can form the basis for public awareness of doctors’ fees.

16. The implications of the Dr Hadiza Bawa-Garba case for Australian doctors

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The case of UK doctor Hadiza Bawa-Garba resonates with Australian doctors, many of whom work in similarly stressed hospital systems.

As widely reported in the media, Dr Bawa-Garba was a fourth-year paediatric trainee in the UK. On her first day back from maternity leave in a new hospital, she was involved in the care of a six-year-old boy named Jack. On this particular day, Dr Bawa-Garba was called upon to cover for absent colleagues. To add to the day’s confusion, the IT system went down. The result of this complete system meltdown was the tragic death of Jack.

While this was a heartbreaking outcome, it is not an unheard of situation. Such a death anywhere in the world would result in legal processes and disciplinary proceedings. However, what happened next in the Dr Bawa-Garba case was completely unexpected and a watershed case in medicine. Dr Bawa-Garba and a nursing colleague were charged and then convicted of manslaughter. Following that conviction, the British medical tribunal imposed a one-year suspension on Dr Bawa- Garba’s practice. The General Medical Council appealed this suspension and the High Court found that as a result of the manslaughter conviction, she should be removed from the register permanently.

It remains hard to understand why Dr Bawa-Garba was ever charged with manslaughter or convicted.

The prosecution’s use of Dr Bawa-Garba’s personal appraisals – required for learning and reflection, has also caused alarm among doctors and medical students.

Everyone has asked, ‘Could it happen here?’

The legal issues around this case are complex and AMA (NSW) is taking legal advice to inform our members about those issues.

However, this case has implications for all doctors in Australia and a national approach to handling similar situations with members needs to be established.

Moved by: Dr Andrew Pesce, Councillor, AMA (NSW)
Seconded by: Prof Brad Frankum

Draft Motion

That our AMA:

  1. Notes the case of Hadiza Bawa-Garba and its implications for doctors in Australia, particularly in light the similar health care systems and stressors;
  2. Take legal advice on the implications of the case for Australian doctors; and
  3. Adopt a position statement that informs doctors of their protections should a similar situation arise in Australia, particularly around the use of personal learning journals.

17. Artificial intelligence in healthcare

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Artificial intelligence (AI) is transforming healthcare. Advancements in these technologies is occurring at a rapid pace and the benefits are exponential.

Medical virtual assistants, apps that interpret lab tests, emotionally intelligent platforms to detect mental illness, bionic hands, AI systems that can outperform radiologists in analysing brain scans for stroke risk, and machines that can analyse biopsies as accurately as pathologists – these are but a few of the ways technology is being used in the healthcare setting, and have the potential to be major disruptors in the way doctors interact with patients.

However, AI needs to be embraced with a circumspect approach. The AMA must consider the challenges to doctors (professionally, legally and ethically) regarding these artificial intelligence technologies.

The AMA has made some headway in dealing with the challenges that AI presents, particularly with regards to the integration of smartphones and tablets, which have become common tools used to access and capture patient information.

Concerns about patient privacy and the potential exploitive use of images meant for medical purposes have led the AMA to develop guidelines on the collection and sharing of digital images (Medical Practitioner Responsibilities with Electronic Communication of Clinical Information - 2013).

However, these technologies raise other issues that have yet to be addressed.

For example, how does the AMA engage with, and ensure that doctors are involved with, the developments coming from big technology companies?

And how will insights from aggregated, anonymous data change the way doctors treat individual patients?

The AMA must be involved in discussions around the use of these technologies in healthcare and therefore needs strong policy guidelines to help inform decisions on the way AI is implemented.

Moved by: Dr Michael Bonning, Board member, AMA (NSW)
Seconded by: Prof Brad Frankum

Draft Motion

That our AMA:

  1. Notes the emerging technologies associated with artificial intelligence and the challenges to doctors – professionally, legally and ethically;
  2. Form a working group to analyse trends in artificial intelligence, its use in healthcare settings and impact on doctors and patients; and
  3. Adopt a position statement and policy that outlines protections and measures for the protection of doctors and patients.

18. Supporting LGBTIQ doctors and medical students

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The AMA’s position statement on Marriage Equality recognises that “there are real and significant mental and physiological health impacts arising from structural discrimination, and the AMA supports moves to eliminate it in all of its forms”.

The marriage equality postal vote brought to light the discrimination members of the LGBTIQ community face in Australia. It also exposed some of the injustices felt by LGBTIQ members of the medical profession.

The AMA needs to do more to support this community by formally recognising the contribution of LGBTIQ medical professionals and supporting their continued role in healthcare.

Moved by: Prof Brad Frankum
Seconded by: TBC

Draft Motion

That our AMA notes the discrimination faced by members of the LGBTIQ community, some of whom are members of the medical community, by adopting a Position Statement that supports LGBTIQ medical professionals.

19. Competitive Neutrality

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Private specialists and public hospital doctors with rights of private practice do not compete on a level playing field – particularly in regional areas.  

Fee competition is distorted because the public hospital specialist with right of private practice can charge the patient “Medicare Only”, pay a facility fee of 15% and take home 85%. In comparison, a private specialist has running costs of 40-50% therefore take home income is reduced to 60%.

This results in solo private specialists having to charge a gap of around 30 percent on top of the common fee to cover practice costs and generate an equivalent  income for doing exactly the same work.

The impact on supply of private practice only specialists in regional centres is considerable. Public hospital specialists who exercise their rights to private practice now outnumber private specialists in many regional centres.

This competition distortion is also detrimental to the AMA membership as more and more solo private practice operators feel disconnected from the AMA agenda.

Moved by: Dr John Cox
Seconded by: TBA

Draft Motion

That our AMA:

  1. Considers the distortion to competition between exclusively private practice specialists and public hospital specialists with rights of private practice; and
  2. Considers the diminished value proposition the AMA membership offers to exclusively private specialists as a result of AMA endorsement of public hospital rights to private practice.

20. Modified Monash Model Classification for all Government programs

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The Federal Government currently uses several different geographical classification systems across different departments. These include the Rural, Remote and Metropolitan Areas (RRMA), the Australian Standard Geographical Classification – Remoteness Area (ASGC-RA), Australian Statistical Geography Standard – Remoteness Area (ASGS-RA), Accessibility/Remoteness Index of Australia (ARIA), the Pharmacy Access/Remoteness Index of Australia (PhARIA) and the Modified Monash Model (MMM).

The MMM classification system categorises metropolitan, regional, rural and remote areas according to both geographical remoteness and town size. It was developed by academics at Monash University with input from key stakeholders. 

The MMM uses the Australian Statistical Geography Standard – Remoteness Areas (ASGS-RA) based on the latest residential population data from the 2011 Census and is about towns and remoteness.

 

Modified Monash Category

Inclusions

MM 1

All areas categorised ASGS-RA1.

MM 2

Areas categorised ASGS-RA 2 and ASGS-RA 3 that are in, or within 20km road distance, of a town with population >50,000.

MM 3

Areas categorised ASGS-RA 2 and ASGS-RA 3 that are not in MM 2 and are in, or within 15km road distance, of a town with population between 15,000 and 50,000.

MM 4

Areas categorised ASGS-RA 2 and ASGS-RA 3 that are not in MM 2 or MM 3, and are in, or within 10km road distance, of a town with population between 5,000 and 15,000.

MM 5

All other areas in ASGS-RA 2 and 3.

MM 6

All areas categorised ASGS-RA 4 that are not on a populated island that is separated from the mainland in the ABS geography and is more than 5km offshore.

MM 7

All other areas – that being ASGS-RA 5 and areas on a populated island that is separated from the mainland in the ABS geography and is more than 5km offshore.

 

The AMA has made previous submissions in relation to the MMM, expressing our support for its use. It is evidence based incorporating other factors such as population size in classifying rural communities. The MMM classification system better differentiates between locations, which under other classification systems would be considered equivalent but which have very different service level challenges. 

Government programs currently using MMM include:

  • GP Rural Incentives Program
  • Bonded Medical Places Program
  • Health Workforce Scholarship Program
  • Indigenous Australian’s Health Program
  • MBS telehealth psychology
  • RFDS program
  • Rural Locum Assistance Program
  • The National Disability Insurance Scheme

This leaves the majority of Commonwealth Government programs operating under other classification schemes that are generally seen as being inferior to the MMM. Provided that the MMM is consistent with the purposes and intent of the design of these programs and appropriate transition arrangements are in place, there appears to be no reason why it should not be extended to the majority of these Commonwealth programs.

Moved by: Dr Dilip Dhupelia
Seconded by: Dr Peter Maguire

Draft Motion

That our AMA calls on the Commonwealth Government to adopt, subject to appropriate transitional arrangements, the Modified Monash Model of Classification for all its workforce and funding programs except where it can be demonstrated that MMM inconsistent with the policy objectives of a program.