Open Letter to Australian Hospitals
To the Directors of Medical Services
11 Dec 2020
RE: Post discharge planning for refugee patients from detention
We are writing to you regarding consideration of the post-hospital destination in discharge planning for patients from Immigration Detention Centres.
Doctors for Refugees (D4R) is an Australian registered charity, whose members are Australian doctors, medical students and other health professionals working to improve access to medical treatment for asylum seekers and refugees in the Australian immigration detention system. We share the position of our colleagues at the Australian Medical Association (AMA) , the Public Health Association of Australia  and almost all other national medical bodies that refugees and those seeking asylum in Australia have the same rights to healthcare as other Australian residents.
While we have every confidence that inpatient care while in Australian facilities will be exemplary, we ask that management consider the post-hospital destination when preparing for refugee patients to leave hospital, and to prevent discharge until the destination is confirmed as being suitable for their medical conditions.
Consideration of post-hospital location of refugees is in keeping with national standards and practices. Discharge planning begins on patient arrival and is part of the standard model of care in Australian hospitals. The Medical Board of Australia’s (MBA) ‘Code of Conduct’ states that good medical practice involves ‘facilitating coordination and continuity of care’  and ‘understanding that when you delegate…you remain responsible for the overall management of the patient’ .
Due diligence requires hospital management to be familiar with the risks and hazards of the post-hospital destination. Through working with cases from detention centres for over seven years, D4R has found that detention facilities are largely unsafe and inappropriate post-hospital discharge locations where adequate continuity of care cannot be obtained. The Australian Human Rights Commission considers onshore Immigration Detention Centres and Alternative Places of Detention to be ‘restrictive’ and to ‘lack features necessary to ensure adequate conditions of detention’ . When medical issues do arise there, there are multiple barriers to access of information and treatment. D4R is aware of several cases of dangerous delay to treatment or transfer to appropriate facilities. In one case it took a visiting lawyer to call an ambulance for a young girl who was extremely ill for several days but whose requests for assistance were repeatedly ignored by staff at the city detention centre. Only then was she finally assessed and admitted to hospital in a serious condition. Such examples are rife in the detention centres.
Prolonged detention times and uncertainty about future or current care have been identified as factors of the Australian detention system that have contributed to ‘alarming levels of mental illness’  where ‘self-harm and suicidal behaviour have become endemic in detention facilities.’ It has been well-documented that ‘detention itself causes or exacerbates mental health concerns.’ Patients’ mental health outcomes cannot be expected to improve if patients remain in prolonged detention and deterioration is entirely foreseeable.
We refer to the MBA’s position that doctors should be ‘aware that these patients may be at greater risk’  and that they should use their ‘expertise and influence to protect and advance the health and wellbeing of individual patients, communities and population.’  D4R urges hospitals and health services to consider the conditions in refugee and asylum seekers’ post-hospital locations and to prevent discharge if deterioration to mental state is considered likely. Discharge planning must involve a risk assessment that takes into account the deleterious effect of the detention environment, and the length of time in this environment on a person’s mental health. As stated by the AMA, ‘medical practitioners should at all times insist that the rights of their patients be respected and not allow lower standards of care to be provided.’
We note that there are already existing systems such as the Sub-Acute and Non-Acute model (SNAP) which factors age, gender, Aboriginal and Torres Strait Islander status, remoteness of location and socio-economic background , and extending this model to include those from immigration detention would be in line with the care provided to other disadvantaged communities. When children, the elderly, people with mental illness and other vulnerable groups are in Australian hospitals it is common practice to prevent discharge until a suitable post-hospital destination can be arranged.
Accordingly, we commend the health professionals at Lady Cilento Hospital in 2016 and other hospital doctors around the country who stood firm to prevent their refugee patients being discharged to unsafe and unsuitable detention environments post-hospital treatment.
While we are mindful of the competing political interests and possible attempts by external agencies to override the expert and considered advice of medical professionals, D4R supports the position of the AMA that doctors should have ‘reasonable professional autonomy and clinical independence without undue external influence.’ 
The Committee of
Doctors for Refugees
 Australian Medical Association, Health Care of Asylum Seekers and Refugees - 2011. Revised 2015, 2015.  Public Health Association of Australia, Refugee and Asylum Seeker Health Policy Position Statement, PHAA International Health Special Interest Group, 2018.  Medical Board of Australia, Good Medical Practice: A Code Of Conduct For Doctors In Australia, Medical Board of Australia, 2014, Section 2.1.3.  Medical Board of Australia, Good Medical Practice: A Code Of Conduct For Doctors In Australia, Medical Board of Australia, 2014, Section 4.3.2.  Australian Human Rights Commission, Risk management in immigration detention, Australian Human Rights Commission, 2019.  Australian Human Rights Commission, Asylum seekers, refugees and human rights. Snapshot Report (2nd Edition) 2017, Australian Governments Open Access and Licensing Framework, 2017.  The Royal Australian and New Zealand College of Psychiatrists, The provision of mental health services for asylum seekers and refugees: Position Statement 46, 2017.  Australian Human Rights Commission, 2008 Immigration detention report - Summary of Observations following the Inspection of Mainland Immigration Detention Facilities, 2008.  Medical Board of Australia, Good medical practice: a code of conduct for doctors in Australia, Australian Health Practitioner Regulation Agency, 2020, Section 3.8.4.  Medical Board of Australia, Good medical practice: a code of conduct for doctors in Australia, Australian Health Practitioner Regulation Agency, 2020, Section 5.3.  Australian Medical Association, Health Care of Asylum Seekers and Refugees - 2011. Revised 2015, 2015, Section 11.  Australian Institute of Health and Welfare, Admitted patient care 2017–18 Australian hospital statistics, Australian Government, 2019.  Australian Medical Association, Health Care of Asylum Seekers and Refugees - 2011. Revised 2015, 2015, Section 14.