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.

 

To find a doctor, or a job, to use GP Desktop and Doctors Health, book and track your CPD, and buy textbooks and guidelines, visit doctorportal.

 

 

15 thoughts on “De-doctoring medicine via another layer of bureaucracy

  1. Maxine Szramka says:

    Hear Hear Aniello. Lets let doctors do the doctoring – and the drawing.

  2. Anonymous says:

    It is becoming arduous jumping through the hoops. I retired from full time practice in my specialty in 2008 and have been working a few months a year in locum positions in public health systems around Australia,

    I am now struggling to work out how I can comply with the “practice improvement” requirements my College has built into its CPD requirements under pressure from this system, as I don’t have a practice I have any control over.

    I may have to simply give up and retire fully, which is sad because I willmiss it, and there is a shortage of people who can do rural locums and I already turn down 10 offers for every locum position I take on.

  3. David More says:

    Just what exactly is the problem this mob are trying to fix???

    I can’t see any real issues with most of the way the profession is governed – except for some over-reach on the part of the APHRA from time to time….

    A period of stability would be good!

    David

  4. Alex J Crandon says:

    More Bureaucratic rubbish cluttering up Medicine. So many Senior Clinicians are retiring and getting out because they are fed up with this interference in medicine by people who have no idea of what they are doing.

  5. Jag Gill says:

    This is typical of thought bubbles of politicians as this reeks of their involvement, perhaps pushed by so-called community organisations and perhaps some involved in the provision of health services to be elevated to positions of authority! Over the last 40 years of working in the system, I have found little improvement in the delivery of services, but an inordinate increase in cost as layers of administration are aded on! So glad that i can leave anytime I choose, but with a heavy heart!

  6. Anonymous says:

    Another useless economist being given power power over something they know absolutely nothing about.for heavens sake. Talk about dumbing down health care in this country. Remember, these are the same morons who clearly forsaw the global recession weren’t they!! Also the first rule of bureaucrat is to ensure they build their bloody empire. Just what this country needs, more useless self important bureaucrats who are simply nothing more than social welfare tax payer funded rent seekers by another name. Where are similar proposals for lawyers, accountants, CEOs, senior miltary people, priests, etc etc all of whom have appalling records. Wake up AMA and the Colleges and tell these moronic politicians and their rent seeking acolytes where they can go and really mean it.

  7. Anonymous says:

    Before you tell me how to do my job, learn how to do my job….

  8. Tim Bailey says:

    HEAR HEAR HEAR HEAR to all of the above and many thanks for this well researched and documented commentary. I’d like to report some personal experience with AHPRA, which is supposedly closer to ‘ground level’ of medical practise than its proposed ‘supervisory’ body described above.
    In a nutshell, i cam across a practitioner who was working in a regional hospital in NSW and was notorious amongst all staff (including allied health , nursing and medical) for being not only dangerous but also actively damaging in his treatment of patients.
    I took it upon myself to report the situation to AHPRA (under whose supervision he was already). AHPRA washed their hands, the Medical Council failed to review and the HCCC declared that his interactions with patients fell “below the threshold for our involvement as he does not constitute a danger to the public” through his practise.!!!!!
    So now, there is a proposal for YET ANOTHER regulatory body, on this occasion with YET MORE non-medical, non-practising and totally inexpert staffers? God give me strength! I certainly won’t be supporting it, or reporting to it.

  9. Anonymous says:

    Bravo, Aniello!
    Hear hear to all the above very valid points.
    Too many cooks spoil the broth.
    Too many non-doctors spoil the medicine.

  10. David Henderson says:

    The Woods proposals are the most sinister attack on the quality of medicine that has been made on the profession and the quality of health care for many years.
    In the name of efficiency and to comply with a policy of government control of all aspects of accreditation, it is propose to give sweeping powers to control education and learning at university and post graduate levels, by giving control of these activities to a body that so far has not distinguished itself. This means that what medical students and trainees learn will be subject to government control and responsive to current government perception of healthcare needs.
    There are several specific proposals that include examining the need for postgraduate hospital training, which is one of the great strengths of the current system and limiting educational input to what is perceived to be the current needs, leading to sort of medical technician work force, capable of carrying out the routine of work, but with insufficient knowledge to provide proper health care.
    These proposals overturn the current system where management of hospital or health services control the resources and doctors as professionals treat patients according to the knowledge they have acquired through education, training and experience. This professional knowledge is, in a sense, owned by the profession and its possession is a source of influence for the profession and hence a problem for managers who want to control and dictate how patients should be treated.
    The proposal seeks to create a situation like the public service, where the corporate knowledge is generated bay the management and employees act according to rules and regulations created by the management.
    Doctors must speak out against this proposal and urge their representative bodies and colleges to resist adoption of these proposals.

  11. JessB says:

    If more doctors were inclined to consider themselves a part of the health system instead of above it- as all of your followers seem to consider themselves- then perhaps we wouldn’t be in the position we are in now. It is completely reasonable for non doctors to be working with and trying to improve the health system- especially as you have just pointed out we are all too busy to do so anyway. Times are changing, doctors are falling from their pedestals and most don’t like it- but the truth is, if you truly engaged in person centred, patient driven care the rewards for patients, doctors and the health system alike would be great.– Just an observation from a BPT seeing their consultants scathing at “bureaucrats” (often medical administrators who are doing their best in a bad system unsupported by their doctor colleagues) but practising bad medicine who don’t even understand hospital funding or how the health system operates.

  12. Anonymous says:

    Beware of foxes in sheeps clothing. People bring in legislation for their own intents and purposes – not necessarily for the reasoning they propose.

    To say; Quote”a health workforce capable of responding to the evolving needs of the community.”Unquote

    I haven’t heard of a community decision of what the community feel their needs are. Have you? Who will make those decisions – the one or two members of the public, [no doubt hand chosen to make it appear an overwhelming majority vote]?

    Quote “It is proposed to give sweeping powers to control education and learning at university and post graduate levels. “Unquote

    This to me is the most disturbing. For decades now, there are those who have got into high places that want to stamp out any advancement in studying the benefits of ‘complimentary alternative medicine (CAM).’

    In 2012 a group of 400 doctors who called themselves “Friends of Science in Medicine” tried to take on Universities from teaching CAM practices. Group co-founder Emeritus Professor John Dwyer from the University of NSW said’ Quote” that FSM wants “vice-chancellors to ask their deans of science what’s the heck’s going on … It’s just extraordinary that such undisciplined nonsense is being taught in universities around Australia. One of the complaints that we have about so-called alternative medicine is that it doesn’t strive to be tested. … “Unquote

    Acting head of the school Dr Ray Myers defended RMIT’s health science programs as “evidence-based education and practice”, RMIT University’s School of Health Sciences has rejected the suggestion that it peddles pseudo-scientific quackery via its courses in complementary and alternative medicine (CAM). Myers said. “RMIT stands by its long record of evidence-based research and the high quality of its health sciences programs.” They are not the only university that I remember going up against Prof. Dwyer 1]

    So, is Australia going to be left behind, because some academic’s want to squash research into CAM? That just doesn’t make sense. My concern is, that it will attempt to do just that, as approximately 70% of Australians want safer solutions without the toxic side effects that some medicines give them. Is it not better that we work together to use the best of both disciplines? As an example, I reference the below:

    This Year’s (2017) Nobel Prize In Medicine Puts Fresh Focus on Ayurveda, the Indian science of health. I quote “The American scientists’ phenomenal research work has left us at an important juncture, where solutions need to be explored. Interdisciplinary and integrative research that blends insights from Ayurveda and modern medicine could probably offer solutions.”Unquote 2]

    Youyou Tu: significance of winning the 2015 Nobel Prize in Physiology or Medicine. Youyou Tu, a female scientist at the China Academy of Traditional Chinese Medicine in Beijing, is the first Chinese winner of the Nobel Prize in Physiology or Medicine. Based on the study of recipes which had been used for thousands of years to treat fever, Tu’s group discovered that the plant artemesia annua, sweet wormwood, showed substantial inhibition of rodent malaria parasites. Her achievement and experience have inspired other researchers and emphasized the development of traditional Chinese medicine. 3]

    One of the other aims; Quote” 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.”unquote

    By whose standards? Unless you are a health practitioner in the Association that overlooks your practice in the modality that you are practicing in, again, what concerns me may be a way of deleting anything from treatment that “they” (who are they?) want to, such as CAM for example.

    We have to acknowledge that the few we give power to, will make decisions for the masses, be it medical practitioners or the public. What we keep silent about is seen as consensus.

    1] https://theconversation.com/alternative-medicine-can-be-scientific-say-besieged-academics-5058
    2] https://swarajyamag.com/science/this-years-nobel-prize-in-medicine-puts-fresh-focus-on-ayurveda
    3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4731589/

  13. Prof Jane Andrews says:

    Very worthy cause wanting to improve service delivery in medicine – esp as much/most of it is publically funded – however more bureaucracy is unlikely to help.

    We already have “alleged” regulatory bodies to enforce/support standards, however we are all aware of instances where they fail to take any interest in substandard practice – until it becomes very obvious.

    There seems to me to be a little of the Weinstein factor going on…….

    Let’s have our existing bodies really look at protecting the public, our purse and the many good ethical doctors trying to up hold standards, by actually examining outlier’s practice with tools available.

    Having been at a 30 year graduation reunion this weekend, I can attest there are many decent, ethical and hard working doctors who do not need more regulation – they need existing bodies to partner with them in supporting the high standards on which we’ve been trained to deliver!

  14. Mark Cantor says:

    Hello Aniello,

    I am a consumer representative. I agree whole heartedly that consumers should not have any input whatsoever to clinical matters. You are correct in the fact that I have no training or expertise to make any meaningful contribution to a clinical situation. My father is about to undergo some fairly radical surgery after a three month course of pre-adjuvant chemotherapy. I believe there are only a few surgeons in Australia capable of conducting this surgery and I don’t want just anyone interfering.

    On the other hand I have spent many many hours with my 80 year old father and mother explaining to them why pre-adjuvant chemotherapy is the gold standard treatment and the best option, while he is terribly fearful of a high grade aggressive cancer growing in his bladder, which he just wants out. Communicating with them in language they understand and raising his confidence with the process and looking after their mental health has taken considerable time and effort. Doctors are a much too valuable and costly resource to undertake this level of consultation. Other people like myself can contribute to the healthcare system to increase the greater holistic value of care. I actually created a small physical analogy to explain the potential of secondary cancers to my father. His oncologist has actually borrowed it to help with other patients.

    I am a systems engineer with post graduate management qualifications and nearly 40 years experience in various high risk industries including Defence, chemical and explosives. Are you saying that there nothing that I might be able to contribute to the governance of the healthcare system? I have just spent 11 days in a major hospital ward with my mother in-law. Being an engineer I cannot help but analyse the lack of systems and the problems that occur on a daily basis that I would love to be able to help fix.

    If I had a pair of forceps I would pull my hair out with the level of frustration I go through.

    Not all healthcare is medicine and doctors. Surely there is a synergy that can be found and I would love to further this discussion and find the synergy.

    Sincere Regards,

    Mark

  15. sociologist says:

    How about returning to the Australian constitution where the Commonwealth is specifically prevented from taking control of Doctors .
    Obviously with politicians who had ignored their simple responsibilities under the constitution – couldn’t even bother to find the status of their parents. How can they cope with sething that requires analysis.
    The public servants know this and confuse the the politicians with ‘new initiatives’ to keep them distracted and make the polliticians think they are doing something that looks like being effective.

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