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De-doctoring medicine via another layer of bureaucracy

THE draft report of the Independent Review of Accreditation Systems within the National Registration and Accreditation Scheme (NRAS) for health professions has been released and it proposes massive changes, and is not to be glossed over.

To remind those who may have forgotten:

The … National Registration and Accreditation Scheme (NRAS) for health practitioners commenced on 1 July 2010. The NRAS has been established by state and territory governments through the introduction of consistent legislation in all jurisdictions. The NRAS is not a Commonwealth Scheme.

In the legislation covering the NRAS, there are six objectives stated in s3(2):

  1. to provide for the protection of the public by ensuring that only health practitioners who are suitably trained and qualified to practise in a competent and ethical manner are registered;
  2. to facilitate workforce mobility across Australia by reducing the administrative burden for health practitioners wishing to move between participating jurisdictions or to practise in more than one participating jurisdiction;
  3. to facilitate the provision of high quality education and training of health practitioners;
  4. to facilitate the rigorous and responsive assessment of overseas-trained health practitioners;
  5. to facilitate access to services provided by health practitioners in accordance with the public interest; and
  6. to enable the continuous development of a flexible, responsive and sustainable Australian health workforce and to enable innovation in the education of, and service delivery by, health practitioners.

The masters of the NRAS – who contrary to the above include federal participants – have now turned their attention to accreditation systems. On 10 October 2016, it was announced that an independent reviewer, Professor Michael Woods, (Professor of Health Economics at University of Technology Sydney) would run a review. Some discussion and consultation led to a draft report released on 4 September 2017.

Professor Woods was allocated staff and resources (state and federal) to conduct the review. It took one week short of 11 months to release the draft. In contrast, people wanting to make submissions had only 6 weeks, with 16 October 2017 being the cut-off date for submissions.

The draft report proposes massive changes and is not to be glossed over. It has professional, financial, ethical, scientific, industrial and educational implications.

It seems unrealistic and inappropriate to expect colleges, associations and individuals to adequately research, consult and prepare a submission on something so monumental in 6 weeks – all during the normal run of business and with no additional resources.

It is likely that very few doctors read the report because of lack of time, lack of publicity and the fact that they will assume someone else read it for them. Sadly, this is the way health policy deteriorates and leaves doctors behind.

The aim of this review is spelled out plainly and simply on the Council of Australian Governments website:

“The aim is to achieve greater cost-effectiveness through consistency and collaboration across professions and delivery of an educational foundation for a health workforce capable of responding to the evolving needs of the community.”

On pages 5 and 6 of the draft report, the Health Education Accreditation Board (HEAB) is proposed, which would place the HEAB above both the health profession accreditation committees as well as the specialist colleges and Postgraduate Medical Councils.

That means that the learned colleges would sit at the bottom of the food chain, with HEAB well above it.

I already have the “HEABie-Jeebies”!!!

One of the main themes in the report is to reduce duplication, but the proposal will in fact create more with this extra layer of bureaucracy. The establishment of HEAB, therefore, is a direct contradiction of the aforementioned guiding principle of reducing red tape.

One wonders where the experts for the HEAB are to come from. Just how many more committees can busy doctors attend on top of their work commitments? We see a class of “meeting attenders” emerge who spend too little time with patients and hence offer weak representation of practitioners who do the real work.

The review (p17) strongly presents the idea of consumer representation:

“Consumers: as end-users of the system, have a right and responsibility to participate in the development and execution of the accreditation standards and processes to ensure the future health workforce is flexible and responsive in meeting the evolving needs of the community.”

This language is disturbing. When I buy a car, I expect that highly educated and experienced engineers have designed the car to the best specifications, especially with respect to safety. I don’t, in any way, see myself as having a right and responsibility to sit on an accreditation panel for those engineers. In fact, I would see my presence as hindering them. Most of the meetings would be spent explaining to me concepts that I am unlikely to absorb.

I have sat on a number of boards over the years and have observed that there is now a band of quasi-professional consumer representatives that do the rounds, in a similar way to professional board directors. I do not feel that this is the spirit of what is intended by consumer representation.

There are some ideas that can only be referred to as daft. The daftest of all is on page 95 of the Draft report):

“… AHPRA [Australian Health Practitioner Regulation Agency] and the National Boards developed a set of principles in 2014 with the stated intent being to shape the thinking about their regulatory decision-making. Although not referenced in the National Law, one of the principles is that ‘While we balance all the objectives of the National Registration and Accreditation Scheme, our primary consideration is to protect the public’.

“The Review considers that this is a retrograde step, with safety and quality potentially being offered as reasons to resist beneficial innovation and the development of a flexible, responsive and sustainable workforce. The range of potential reforms identified by the Review, and set out in this Report, recognise the critical importance of the education of the health workforce in being able to respond to and shape future directions in health service delivery and access to services.”

So, the first rule of medicine (primum non nocere) and the first principle of the NRAS (to provide protection to the public), listed above, are secondary, according to this report.

Another interesting principle is stated on page 12 of the draft report:

“AHPRA, in partnership with National Registration Boards and the Accreditation Board, should lead discussions with the Department of Education and Training and the Department of Immigration and Border Protection to develop a one-step approach to the assessment of overseas trained practitioners for the purposes of skilled migration and registration.”

One can imagine the composition of such a committee and how medical qualifications and clinical experience will be drowned out by other considerations. Given that other strong themes of the report involve merging assessment of different health professionals and role substitution, it is possible that assessment of doctors by such a committee may not even involve doctors.

Medicine is a complex, adaptive system that is arguably the hardest profession to practise well. The checks and balances put in place in Australia may be hard but they do allow our profession and the public to be reassured that quality and safety are paramount.

This report lowers the bar way too much. The focus on saving money and task substitution is misguided and will result in a weaker profession and compromise of public safety.

It is little wonder that the likes of the Council of Presidents of Medical Colleges, the Australian Medical Association and the Australian Doctors Federation are all speaking out against this report.

We all know that colleges may be imperfect; however, they are dedicated to the principles of patient care, scientific progress and education. The proposals in this report mean our profession is being reduced to a workforce.

For AHPRA to think that it can lead workforce reform is misguided. Our profession – without the help of AHPRA — has already achieved interesting workforce solutions, such as the Prevocational General Practice Placements Program, rural generalist programs and the Remote Vocational Training Scheme.

The Royal Australasian College of Surgeons has led the way in addressing professional behaviour and standards, again without the help of AHPRA.

If this draft report into accreditation seeks to solve distribution problems, the bad news is that it will not. By muddying the waters of role delineation, creating more layers of administration and involving more non-clinicians, it will only hinder workforce development.

I conclude by summarising the track record that AHPRA has racked up since its inception:

  • it implemented mandatory reporting;
  • it has higher fees;
  • NSW refuses to relinquish the Health Care Complaints Commission;
  • it allowed non-medical chairs of medical boards;
  • it created an amorphous structure without state borders, which makes accountability and complaints against it almost impossible;
  • it tried to impose revalidation; and
  • it has introduced this review into accreditation.

The theme is very clear: de-doctoring medicine!

I think it is time our politicians abandon AHPRA and go back to the drawing board. And they should let doctors do the drawing.

Dr Aniello Iannuzzi, FACRRM, FRACGP, FARGP, FAICD, is a GP practising in Coonabarabran, NSW, and a clinical associate professor at the University of Sydney.

 This article was originally posted  on MJA InSight https://www.doctorportal.com.au/mjainsight/2017/42/de-doctoring-medicine-via-another-layer-of-bureaucracy/

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