Lessons Learned, Changes Made- a new era in Australia

Dr Joanna FlynnChairMedical Board of Australia

Outline

Australia past and present The sorry saga of Dr Patel The new era in health professions regulation

Where did it come from? What is it? How does it work?

Enduring challenges in medical regulation in Australia

Brief history of Australia

• First Australians arrived > 50,000 years ago• Terra Australis – imagined by Aristotle, seen by

Portuguese, Spanish, French, Dutch 16th - 18th C• Australia claimed for Britain by James Cook 1770• British Penal Colonies 1787-1868;160,000 convicts• Free settlers from 1790’s• Gold rush, farming, mining• 1901 Federation of six states, population 4M

Australia today• Total population 22.5 million, urban 89%• 25% resident population born overseas

– UK 23%– NZ10%– China 6%– Italy 5%– Vietnam 4%– India 3%

• Median Age 37

Historical context of regulation

• Council of Medical Examiners, Van Diemen’s Land (Tasmania)• NSW 1838 then other states and territories (GMC UK 1858)• Powers initially limited to registration, later included

investigation and disciplinary processes• More recently – impairment, performance, codes, guidance• Changing from Medical Acts to cross profession legislation

e.g. Health Professions Registration Act 2005, Victoria

Changes already occurring

• Increasing community involvement• Public access to information

– About those on the register– About Board processes and outcomes

• Separation of Powers• More oversight and scrutiny• Greater accountability

Is medical regulation failing?- the sorry saga of Dr Patel

TimelineApril 2003: starts work at Bundaberg HospitalJun 2003: Nurse Toni Hoffman first raises concernsIn 24 months over 20 complaints by staff/patientsFeb 2005: Qld Health begins investigationMar 2005: concerns raised in ParliamentApril 2005: Patel resigns, flies back to OregonApril 2005: media reveals US history

Timeline (2)

April 2005: Premier announces Morris inquirySep 2005: Morris enquiry axed by Supreme Court over

ostensible bias against 2 Qld Health employeesSep 2005: Davies inquiry reported Nov 2005Nov 2006: warrants issued for Patel’s arrest, 16 charges

include manslaughter, GBH, fraudJul 2008: Patel extradited to BrisbaneFeb 2009: committal hearing

Timeline (3)

Jun 2010: jury finds Patel guilty three counts of manslaughter, one count of GBH after 15 week trial

July 2010: sentenced to seven years jailAug 2010: Patel appeals against conviction and sentence

and Attorney General appeals against leniency of sentence

Nov 2010: Patel’s appeal scheduledFraud and other proceedings outstandingCurrently in jail

Evidence to Commission of Inquiry re Patel

“Dr Patel’s results were not ten times worse than one would expect; they were one hundred times worse”

• unacceptable care contributed to 13 deaths• unacceptable care may have contributed to 4 deaths• poor care contributed or may have contributed to

adverse outcome in 31 surviving patients“Incompetent”

Commission of Inquiryfindings re Medical BoardDr Patel was registered because• negligent omission by the Medical Board to advert to a

notation on Dr Patel’s Certificate of Licensure from Oregon

• negligent failure by Board to make inquiries about Dr Patel’s past practice in the United States

• negligent failure by Medical Board to assess his qualification and experience suitable for position

Patel’s Registration in Qld

• Feb 2003: registered to fill area of need as senior medical officer Bundaberg Base Hospital having declared he had no current suspension or cancellation and no history of restrictions imposed by any registration authority

• Jan 2004: further registration granted as Director of Surgery

• Feb 2005: further application deferred on basis of concerns raised in Bundaberg

• April 2005: review by Board revealed orders of Oregon BME, NY Office of Professions

Known disciplinary record

1984: NY BPMC disciplined Dr Patel during his residency for entering histories without examining patients, failure in record keeping, harassing a patient for cooperating with NY investigation: six month license suspension with stay, 3 years probation, fines

1989: Registered in Oregon2000: BME Oregon disciplined Patel for gross or repeated

acts of negligence and unprofessional conduct and placed restrictions

So what did we learn?

• Review the integrity of registration processes– Identity, primary source verification– Question gaps in CV– 10 yr history from previous registration bodies– Criminal history checking

• Pre-employment assessment - suitability for role• Supervision processes and monitoring• Responsiveness to concerns• Mandatory reporting

A new era in health professions regulation in Australia

The new scheme - NRAS

National registration and accreditation scheme (NRAS) fora) The regulation of health practitionersb) The registration of students undertaking

i. Programs of study that provide a qualification for registration in a health profession; or

ii. Clinical training in a health profession

Where NRAS came from…

• Concerns about health workforce shortages, rigidity• Concerns about adequacy of regulatory processes• Feb 06 - Productivity Commission report- Australia’s Health Workforce

– recommended single cross profession accreditation and registration boards

• July 06 - COAG announced NRAS – to start July 08 “to facilitate workforce mobility; improve safety and quality; reduce red tape; simplify and improve consistency”

• March 08 - COAG signed Intergovernmental Agreement with implementation date 1 July 2010

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Before July ‘10

• Eight States and Territories• > 85 health profession

boards• 66 Acts of Parliament

Since July ‘10

• One national scheme (+WA)• 10 health profession boards

(+WA)• Nationally consistent

legislation

Legislation…

• Act A – The Health Practitioner Regulation (Administrative Arrangements) National Law Act 2008 (Queensland)

• Act B – Health Practitioner Regulation National Law Act 2009 - Full provisions for operation of the scheme, commenced 1 July 2010

• Acts C – Adoption and Consequential Bills in each jurisdiction progressively in the past 12 months

Guiding principles…• national scheme to operate in transparent, accountable,

efficient, effective and fair way• registration fees to be reasonable (having regard to the

efficient and effective operation of the scheme)• restrictions on practice to be imposed only if necessary to

ensure health services provided safely and of appropriate quality

Objectives… • Provide for protection of the public by ensuring that only practitioners

who are suitably trained and qualified to practice in a competent and ethical manner are registered

• Facilitate workforce mobility across Australia• Facilitate provision of high quality education and training of health

practitioners• Facilitate rigorous and responsive assessment of overseas practitioners• Facilitate access to services in the public interest• Enable continuous development of a flexible, responsive and sustainable

Australian health workforce and enable innovation in education and service delivery

Structure…Ministerial Council

Advisory Council National BoardsAgency

ManagementCommittee

National Committees

State/ Territory/ RegionalBoards

National Office

State and TerritoryOffices

Support

Support

Support

AccreditationAuthorities

Contract

Advice

Health Professions…July 2010• chiropractors• dental care (including dentists, dental

hygienists, dental prosthetists & dental therapists),

• medical practitioners • nurses and midwives• optometrists• osteopaths • pharmacists• physiotherapists• podiatrists• psychologists

July 2012• Aboriginal and Torres Strait

Islander health practitioners• Chinese medicine

practitioners• medical radiation

practitioners• occupational therapists

NSW…

• Registration will be national and registration decisions will be made by National Board

• Performance, health and conduct will be managed under NSW scheme in a co-regulatory model with Health Care Complaints Commission (HCC)

• HCC retains role as independent investigator and prosecutor

Role of National boards…• Set national standards, codes and guidelines• Determine requirements for registration• Approve accredited programs of study• Oversee assessment of overseas trained practitioners• Oversee receipt and follow-up of notifications on health,

performance and conduct• Maintain registers (with AHPRA)• Delegate powers to staff, committees• Set registration fees and develop Health Profession

Agreement with AHPRA

Role of AHPRA…• …all functions in line with the objectives and guiding

principles of the scheme

• …provide support and administration services to National Boards and committees, through one organisation with a National office and State/Territory offices

• Health Profession Agreements with National Boards:– employ staff– manage contracts– own and manage property

Key features of national law…

• Registration standards– Criminal history– English language proficiency– Recency of practice– Mandatory continuing professional development– Mandatory professional indemnity insurance

• Mandatory Reporting of notifiable conduct• Student registration• Independent accreditation functions

– Australian Medical Council appointed for medicine

Key features …• Boards appointed by Ministerial Council• Two thirds practitioners, one third community• Members from each jurisdiction with • Initial membership drawn from existing state and territory

medical Boards• Previous medical boards now committees of national board• Chair of each Board a practitioner member• National registration fee for each profession• Self-funded from registration fees, no subsidies• No cross profession subsidisation

Mandatory notifications…

• Practitioners and employers must report a registrant who they reasonably believe has engaged in notifiable conduct (some exceptions)

• Belief formed through the practice of the profession• Not limited to notifications in same profession as practitioner• Notifiable conduct is:

– practising while intoxicated by drugs or alcohol– engaging in sexual misconduct in connection with professional practice– placing the public at risk of substantial harm through a physical or mental

impairment affecting the person’s capacity to practice– placing the public at risk of harm through a significant departure from

accepted professional standards

Notifications…

• Act also allows for voluntary notifications• Protection from liability for persons making notifications

or providing information in good faith

Conditions…

• Conditions of registration will be shown on the Register (publicly accessible)

• Where health conditions are in place note on Register that the practitioner is subject to health conditions – details of conditions not provided

Progress so far…• All states except WA up and running• National on line register• Code of conduct Good Medical Practice endorsed• Registration Standards approved by Ministers• Transition ~ 500,000 registrants to the National Law• Health Professions Agreements• Agreements with Accreditation Agencies• Mandatory reporting guidelines issued• Advertising guidelines issued

Registration in new scheme

Registration type/subtype Number

General only 24,236

General & Specialist 38,026

Specialist only 5,594

Limited

Public interest – occasional practice 1,410

Teaching/research 185

Area of need 2,069

Public interest 494

Postgraduate training 3,442

Non-practising 2,475

Provisional 2,180

Noticeable Differences

• Registration fees• Requirements for CPD, Recency, PII • Specialist registration• Identity – AHPRA, MBA• Communication and relationships• Policies and procedures• Outcomes?

Where to from here?

Medicine has perennial moral problems, two of which are particularly serious in the present age: insensitivity to suffering and abuse of power

Ian McWhinneyPatient-Centered Medicine 1995

Professional Responsibilities of Medicine

All doctors must accept seek trust and deserve it as their moral law

Patients and society rely on medicine to be trustworthyPatients do trust because a history of doctors acting for

their patients’ good has made medicine trustworthy

Rosamond Rhodes The Blackwell Guide to Medical Ethics 2007

Some of the real problems

• Workforce shortage and maldistibution• Burnout and low morale• Safety, quality and appropriateness of services• Distortions driven by payment systems• Gap in expectations

– of healthcare– of regulation

Challenges in accreditation

• Should Australia have a licensing assessment for all?• The medical education continuum – linking it up• The burden of accreditation• Emerging areas of practice & roles (e.g. cosmetic

medicine, physician assistants)• Very large increase in numbers of medical students• Funding

Biggest issues – plus ça change

• Assessment and supervision of IMGs

• Proportionate and timely responses

– Separating big issues/ less serious/ non issues

• Frivolous or vexatious – both doctors and public

• Should system be entirely self-funded?

• The confidence of the public and the profession

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Enduring challenges…

• Credibility – “one bad apple” – greater risk in national scheme?

• The view that any doctor is better than no doctor• Perceptions: old boys club, out of touch, too punitive, too

soft or focussing on wrong issues• Ensuring ongoing competence and performance

The future…Transparent, accountable, efficient, effective, fair

regulationRespected source of advice and guidanceResponsive, adaptive, open, outward facingEngaging with profession and communityFinancially sound with reasonable feesA framework to maintain trust