AMA Joint Submission on the
Proposed Arrangements for Accreditation
for the National Registration and Accreditation Scheme
for the Health Professions
(the scheme) 

Executive Summary

This joint submission is made by the Australian Medical Association (the AMA), the Royal Australian College of General Practitioners, the Australian Society of Plastic Surgeons, the Australian Association of Surgeons, Australian & New Zealand Intensive Care Society, the Council of Procedural Specialists, the Australian Society of Orthopaedic Surgeons, the Australian Salaried Medical Officers' Federation, the Australian Society of Otolaryngology Head & Neck Surgery, the Australian Association of Pathology Practices, the Australian College of Rural and Remote Medicine, the Australian Orthopaedic Association, the Australian Society of Ophthalmologists and the Australian Society of Anaesthetists (the co‑signatories).

We remain very concerned that, in the context of a workforce reform agenda, the architecture of the scheme, particularly in respect of the accreditation arrangements, will permit the lowering of professional standards with consequences for patient safety and quality of care. We can find no evidence or justification for the model of accreditation of medical education and training and clinical standards setting proposed by the Council of Australian Governments (COAG) and delivered via the Intergovernmental Agreement (the IGA).

The Australian Medical Council (AMC) is the independent national standards body already established for the purpose of accrediting medical education and training, providing advice on the recognition of medical specialties and advising on the maintenance of professional standards in the medical profession. There is no case to dismantle these arrangements, which currently meet international guidelines and therefore ensure our medical courses have international recognition.

The AMA and the co-signatories continue to hold grave concerns for the future standing of accreditation of Australian medical education and training courses. We are very concerned that:

•  Accreditation of medical education and training will not be independent of government, providing the potential to lower standards and therefore compromise patient safety and health outcomes.
• Loss of the independence of accreditation of medical education and training will mean that Australian medical education and training courses will no longer meet international guidelines.

The combination of the administration of the registration and accreditation functions will provide a vehicle to systematically lower standards for medical education and training and professional practice.

Further, we are concerned there is insufficient accountability for Ministerial decisions and policy directions on accreditation standards. While the Health Practitioner Regulation (Administrative Arrangements) National Law Act 2008 (QLD) requires Ministerial decisions to be published, there is no requirement for this to happen in a reasonable timeframe. Consequently, there could be long lead times before the public is aware that standards have been systematically lowered, particularly for Ministerial decisions that are inconsistent with advice provided by the professional board or the independent accrediting body.

The AMA and the co-signatories remain committed to maintaining excellence in medical practice in Australia. This could be achieved through the wholesale inclusion of the existing AMC accreditation arrangements into the proposed scheme, including its functions, activities and governance arrangements. The consultation paper on the proposed arrangements for accreditation should have clearly set out how this would occur. In the absence of that, the AMA and the co‑signatories want an assurance from government that it will include these existing arrangements in the scheme.

Independence of medical education and training
The AMA and the co-signatories will continue to argue that the independence of accreditation of medical education and training in Australia will no longer be protected under the proposed scheme. This is because Health Ministers, not boards, will have final approval of, and be able to issue policy directions on, accreditation standards. The mere fact that Ministers cannot make decisions on accreditation of individual courses does not make the proposed accreditation arrangements independent of government.

Every part of accreditation of medical education and training should be independent of any political process. The public's confidence in the accreditation process to deliver the highest standards of medical education and training, and consequently patient safety and quality care, must be protected. This requires a process that legally obliges Ministers to accept advice from an independent accrediting agency via the national medical board. To achieve this, we believe that the independent accrediting body should have formal delegated authority in respect of developing and approving accreditation standards as well as for decisions to accredit individual courses.

Further, in order for the accreditation function to be independent of government, the legislation will need to guarantee that there is also no interference from the National Agency in respect of accreditation standards. The legislation should contain explicit provisions that preclude the National Agency from making decisions that impact either on the content, or administration, of accreditation standards.

If the independence of the accrediting body for medical education and training is not retained, there is a real risk that standards for accreditation of medical education and training could be eroded and manipulated. This is because Ministers will be able to influence (via policy directions) professional and accreditation standards to address workforce issues or achieve cost savings. For example, a direction could be issued encouraging accreditation agencies to accredit shortened training courses. Through policy directions from Ministers on accreditation standards and/or the influence of the National Agency on the accrediting body, inappropriately short courses could then be accredited in future as a means of introducing a rapid process for bringing people into the health workforce.

There is nothing in the consultation paper that serves to allay these fears.

Accreditation will not meet international guidelines
The proposed framework for accreditation does not meet the World Health Organisation/World Federation for Medical Education Guidelines for Accreditation of Basic Medical Education (Geneva/Copenhagen 2005). Under these guidelines, the legal framework for a country's system of accreditation of basic medical education should:

• secure the autonomy of the accreditation system and ensure the independence of its quality assessment from government, the medical schools and the profession; and
• authorise the accrediting body to set standards.

As stated above, Ministers will have final approval of, and be able to issue policy directions on, accreditation standards. Not the boards. And certainly not the accrediting bodies as required by the guidelines.

As the proposed legal framework does not meet the international guidelines, we are concerned this may impact on the high standing of Australian trained doctors and their ability to have their training recognised in other countries. The AMA and the co-signatories believe it is the responsibility of Government to consult international medical recognition organisations to ensure there are no future unintended consequences from introduction of the scheme for Australian trained medical practitioners intending to practice overseas.

Similarly, the proposed scheme also puts at risk the standing of international medical students studying in Australia.

Other governance issues for the existing accrediting body
Under the IGA the National Agency lays down the standards and criteria for the establishment, governance and operation of the accrediting bodies. Section 3.5 of the consultation paper emphasises the control the National Agency will have over accrediting bodies. It states that existing accreditation bodies will have to reconstitute their governance arrangements to accord with National Agency standards, guided by the Health Ministers. The AMA and the co-signatories note that this requirement may impose additional costs on existing accrediting bodies that are assigned functions under the scheme.

Further, the AMC currently undertakes a range of functions beyond those proposed in the scheme for independent accrediting bodies. The AMC should not be beholden to the National Agency to carry out these functions in accordance with the governance arrangements set by the Agency.

Combining registration and accreditation functions
Bringing together responsibility for the approval of both registration and accreditation standards under Ministers will enable health workforce reform by stealth. The architecture of decision-making under the scheme, as set out in the IGA and proposed to be enshrined in the new legislation will facilitate future changes in roles and responsibility across the health professions without evidence, scrutiny or public and professional debate.

This has been confirmed by proposal 3.4.6 in the consultation paper that the legislation permit boards to expand the scope of courses which they accredit. This will have the effect of enabling boards to expand a particular profession's scope of practice.

There is no proposal in this or other consultation papers, or provisions in the Health Practitioner Regulation (Administrative Arrangements) National Law Bill 2008, that will prevent boards from making recommendations in respect of their own education and training and scope of practice in a silo. There is also no requirement for Ministers to consult with other professions when approving accreditation standards for an expanded scope of courses.

Further, we are very concerned that Ministers will be able to influence the board's decisions to expand the scope of practice and the courses a board can accredit by issuing policy directions on workforce or training issues generally as well as standards and competencies.

As we have stated above, over time, the role of the National Agency could evolve into one where the Agency also has an inappropriate influence on the accreditation and professional standards. Indeed, without explicit legislative protection, the National Agency could even interfere with decisions on accreditation of particular courses. The proposed scheme does not have sufficient clarity about the decisions that the National Agency can, and cannot take. The role of the National Agency must be articulated in more detail and the legislation must ensure that the Agency is explicitly prevented from interfering with any of the professional operations or decisions of the professional boards to accredit courses.

The consultation paper at section 3.7 justifies combining the registration and accreditation functions only on the basis that it will remove the potential for conflicting outcomes from the two processes. We are yet to see evidence that demonstrates that such a problem exists and that combining the two functions is the only solution.

In any case, it ignores the Productivity Commission's view that good regulatory practice would separate the accreditation and registration functions1.

Instead, combining the two functions will facilitate the expansion of scopes of practice for non-medical health professions, and without any reference to the medical profession. This will not be good for health care in this country. It will lead to fragmented, uncoordinated care.

In respect of training, it will lead to competition for clinical training resources. It will also lead to changes in professional roles by virtue of changes to the scope of training.

Assessment of overseas qualifications
The consultation paper makes some high level comment about possible processes for assessment of overseas medical education and training courses and the assessment of individual medical practitioners for the purposes of registration in Australia. There is no detail on the processes that are being proposed for the scheme, and so it is not possible to make any comment in this regard.

In February 2006 the Council of Australian Government agreed to introduce nationally consistent assessment processes for international medical graduates. A great deal of progress has been made towards this objective, with the development of more robust and transparent assessment processes. Where possible, more streamlined assessment arrangements have been agreed.

Many of these changes have been implemented through a cooperative approach involving the AMC, medical colleges, medical boards, the medical profession, health departments and relevant stakeholders. While the final stages of these reforms are still in the process of being introduced, the reforms to date have significantly improved the arrangements for permitting international medical graduates to practise in Australia. In recognition of the higher risks to patient safety and the differing standards of overseas medical qualifications, the new arrangements have been tailored to the very specific circumstances of the medical profession. They have taken over three years to develop and implement. The AMA and the co‑signatories oppose any proposal to change these arrangements before they have had time to be bedded down and properly evaluated.

Cost of accreditation function to be drawn from registration fees
The paper variously proposes that the cost of the accreditation function be drawn from registration fees. This will significantly add to the cost of registration of a medical practitioner. Currently, organisations providing medical education and training pay fees to the AMC to be accredited. Further, the cost of assessing overseas trained doctors is met by individuals seeking recognition.

These arrangements must continue. It is not appropriate for registrants to support these functions through registration fees.

Conclusion
Australian trained doctors are highly regarded internationally and Australians receive high quality medical services. This is because the AMC does a very good job of developing and establishing accreditation standards for medical education and training, and accrediting individual courses. There is no reason to change these arrangements, either in terms of efficiency of AMC processes or effectiveness of current governance arrangements.

Government has provided no justification for proposing, or evidence to support, the introduction of completely new arrangements for the accreditation of medical education and training in Australia.

The AMA and the co-signatories oppose a scheme that does not transparently incorporate the AMC with its current governance arrangements into the scheme.

Further, it is critical that patient safety and quality of health care remain paramount and are protected in the longer term through appropriate governance, transparency and accountability in the legislation underpinning the accreditation arrangements.

Dr Rosanna Capolingua
President
Australian Medical Association

Dr Rod Pearce Chair AMA Council of General Practice	Dr Alex Markwell Chair AMA Council of Doctors in Training
Dr Peter Beaumont President AMA Northern Territory	Dr Christopher Davis President AMA Queensland
Dr Brian Morton President AMA New South Wales	Dr Paul Jones President AMA Australian Capital Territory
Dr Douglas Travis President AMA Victoria	Dr Chris Middleton Acting President AMA Tasmania
Dr Peter Ford President AMA South Australia	Dr Gary Geelhoed President AMA Western Australia

Dr Chris Mitchell
President
Royal Australian College of General Practitioners

Dr Howard Webster, MBBS (Hons) FRACS (Plast) MBA
President
Australian Society of Plastic Surgeons

Mr John A Buntine
President
Australian Association of Surgeons

Dr Peter Hicks
President
Australian & New Zealand Intensive Care Society

Dr Gary Speck
Chairman
Council of Procedural Specialists
and
Australian Society of Orthopaedic Surgeons

Christopher J Verco
Federal President
Australian Salaried Medical Officers' Federation

Dr Stuart Miller
President
Australian Society of Otolaryngology Head & Neck Surgery

Dr Ian Clark
President
Australian Association of Pathology Practices

Assoc Prof Dennis Pashen
President
Australian College of Rural and Remote Medicine

Mr John Batten
President
Australian Orthopaedic Association

Dr Russell Bach
President
Australian Society of Ophthalmologists

Dr Elizabeth Feeney
President
Australian Society of Anaesthetists

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