Dr Don Kane discusses systemic bullying of health professionals – tolerated by the national regulatory body – and highlights the need for reform.
Hedley Thomas has earned well-deserved recognition as one of Australia's most highly regarded investigative journalists.
His article 'System protects dangerous surgeons' in the “The Australian” (29 February), raises genuine concern and has revealed one aspect of the problems in medical regulation but does not address all the issues.
Annual self-audits of performance for surgeons have been required to review competence. A reasonable requirement, this was initiated to protect the community — not to protect incompetent surgeons.
But a new level of assessment is required for reasons of transparency. The audit should not be a self audit — it should be done by an independent practitioner who has a similar practice pattern. This would be a more robust system and avoid sham audits.
The Health Professionals Australia Reform Association (HPARA) is critical of the College of Surgeons and other colleges who do not protect competent members from vexatious complaints to the regulatory authority, Australian Health Practioner Regulation Agency (AHPRA) — or from administrators and colleagues who target practitioners for reasons other than clinical issues.
These complaints include alleged “poor communication skills” when the victim has been practising for a number of years without any problems in delivery of services. Bullying of junior and senior health practitioners for non-clinical issues has been tolerated by AHPRA and administrators who do not recognise that personal and commercial reasons are the genesis of attacks.
' ... nine recommendations were approved for immediate implementation, a further 18 were either approved in principle or deferred pending further advice on alternative approaches. Essentially 27 of the 33 recommendations are under active consideration by the Ministerial Council.'
A lack of detailed knowledge of the functioning of health services delivery and the working environment for health professionals in bureaucrats, administrations – including those in AHPRA – and politicians plus their advisors is the problem.
A serious consequence of the current approach by APHRA, administrators and malevolent colleagues is that it is common for the targeted practitioner to be highly skilled, knowledgeable and successful. There are many cases where the community has been denied the services of such practitioners as a result of these activities.
The assessment system in AHPRA appears flawed and frequently seems to deny natural justice and presumption of innocence to accused practitioners. There is inadequate investigation of a complaint before placing conditions (restrictions) on the registration of a notified practitioner. The decision-makers in the organisation have immunity from any legal action even when an action has been proven to be wrongful. There is no accountability.
There are numerous examples where individuals have placed themselves in influential positions throughout the regulation and administration of health practitioners within colleges and administrations. This seems to result in failure to declare conflicts of interest as well as inappropriate decisions.
A fair go is long overdue for health professionals who are the victims of vexatious and malicious attack.
Dr Kerry Breen, a former president of both the Medical Practitioners Board of Victoria and the Australian Medical Council, last month called the National Scheme an expensive, five-year experiment that had partly failed.
Dr Breen alleged numerous problems with the scheme, and called for AHPRA's powers to be pared back so that it merely maintains the national registration database.
Mr Fletcher has responded to the criticisms in an opinion piece supplied to Medical Observer:
In his recent comments, Dr Kerry Breen criticises the National Scheme regulating health practitioners and refers to the Independent Review of the scheme carried out for Health Ministers. He doesn’t mention that Health ministers agreed with the assessment of the Independent Reviewer that while some changes will improve things, the National Scheme is acknowledged as among the most significant and effective reforms of health profession regulation in Australia and internationally.
Ministers highlighted that the community can have confidence that health professionals providing treatment and care in Australia meet a national standard based on safe practice; that there is increased mobility for individual practitioners because they no longer need to be separately registered in each jurisdiction, and; the public is better protected because health practitioners who have committed misconduct and faced regulatory action can no longer practise undetected in other states or territories. There is now a national public register that shows if a practitioner has restrictions on their registration.
The national regulation of more than 630,000 health practitioners – including 100,000 medical practitioners - is undoubtedly a large and complex undertaking. I would be the first to say the National Registration and Accreditation Scheme is not perfect and that there continue to be areas to improve. However, I am also confident that we have taken major strides over the past six years and it is getting better all the time.
Dr Breen also highlights the findings of the NRAS Review in relation to the need to improve our response to complaints about medical practitioners. This is an important area in which we have worked very hard to reduce timeframes, improve communications and ensure good regulatory decision making. Over the past year alone we have halved the number of days it takes to close matters at assessment if no further regulatory action is required and reduced by one third the number of days involved in completing our management of a notification to a regulatory outcome.
While Dr Breen has not discussed his recent “review” of our work with me, I understand he made an enormous contribution to the regulation of medical practitioners in Victoria some time ago. I respect his views and understand the temptation to look back on the past fondly.
Not everyone understands how the National Scheme works. Let me start with AHPRA. We are a national organisation with a local focus and a local presence in every state and territory with direct accountability to all health ministers. We administer the day to day work of national registration in partnership with boards. We have clear lines of accountability and reporting to Health Ministers both individually and collectively and to state and territory parliaments. See ahpra.gov.au/annualreport/2015.
Strong local relationships are critical for us to do our job well. Dr Breen writes of the importance of strong connections with the community and the professions. We agree. Our trustworthiness in the eyes of both the community and the professions we regulate is essential.
So how are we trying to achieve that goal?
Let me take the example of the regulation of doctors in Victoria, Dr Breen’s home state. On a day to day basis, it is not that different from what happened before the National Scheme. There is a local Victorian Medical Board. It is appointed by the Victorian Health Minister. It is made up of both Victorian doctors and community members. It makes all of the regulatory decisions about medical practitioners in Victoria, who are assessed against national standards. These decisions draw on the careful judgement of Board members, based on the issues before them and their deep understanding of the Victorian health context.
The Victorian Board is supported by a local team of AHPRA staff in our Victorian office. A number of our staff worked with regulatory boards in the previous system. The Board and AHPRA work closely with the local Health Services Commissioner, the Victorian Department of Health and Human Services and deal with the local Tribunal (VCAT) for serious matters.
Similar arrangements are replicated in most other states and territories, noting differing arrangements for co-regulation in NSW and Queensland. This is how the National Scheme strikes a balance between the benefits of a national approach and the strength of local arrangements for dealing with individual medical practitioners.
Dr Breen argues that our move towards national regulation has seen us drop behind our international counterparts such as Canada, where he argues different medical boards across the provinces and territories continue to drive competition and improvements. This opinion stands in stark contrast to a report on health care quality released by the OECD last year, which found that Australia’s ‘national system for regulating 14 health professions makes Australia a leader among OECD countries’.
The National Scheme is something of which to be proud. We need to keep building on the opportunities it creates to serve the Australian community better. I am always open to ideas for improvement, but believe it would be unwise to ‘turn the clock back’ on the system of medical regulation in Australia, create more upheaval and risk the benefits of what has been achieved to date.
For more information on the Health Professionals Australia Reform Association (HPARA) please email firstname.lastname@example.org or call 0499 399 081.
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Australia License
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