AMA Joint Submission on the
Proposed Arrangements for Specialists within 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 Otolaryngology Head & Neck Surgery, the Australian Society of Anaesthetists, the Australian Society of Ophthalmologists, the Australian Society of Plastic Surgeons, the Australian Association of Surgeons, the National Association of Specialist Obstetricians and Gynecologists, the Australian and New Zealand Association of Urological Surgeons, the Urological Society of Australia and New Zealand, the Council of Procedural Specialists, the Australian Society of Orthopaedic Surgeons and the Australian Orthopaedic Association (the co-signatories).

The AMA and the co-signatories support national registration arrangements and consistent standards for the medical profession across Australia.  We support a scheme that ensures that only suitably trained and qualified medical practitioners are able to practise and provide Australians with safe, high quality medical services.

Protection of the public
We remain opposed to the overarching architecture of the Intergovernmental Agreement (the IGA) and the scheme.  It does not protect Australians from underqualified medical practitioners working outside of the scope of their training and practice. 

Further, the proposed scheme does not protect Australians from receiving care and treatment from health professions acting in a capacity beyond their education and training.  In fact, it provides a mechanism to enable this.

We remained very concerned that, in the context of a workforce reform agenda, the architecture of the scheme will permit the lowering of health professional standards with consequences for patient safety and quality of care.

The consultation paper on the proposed arrangements for specialist health practitioners confirms our deepest concerns that the scheme will be a vehicle for governments to respond to workforce challenges by:

• permitting people to be registered as medical practitioners even though they do not meet the requirements for general medical registration; and
• allowing other health providers to inappropriately undertake competencies beyond their training and scope of practice. 

The proposed scheme will allow this to occur without parliamentary or public scrutiny.  At this late stage of the consultation process, we are not convinced that governments have heeded any concerns about the specific proposals that pose serious risk to patient safety and quality and to quality of care.

The role of the medical colleges
In our previous submissions to government we have clearly outlined our concerns about the potential disenfranchisement of the medical colleges and the importance of retaining their role in setting and maintaining medical specialist standards. 

As this latest consultation paper is again silent on the explicit role of medical colleges, we can only assume government does not intend to guarantee in writing, and indeed in legislation, the role of medical colleges in:

• determining specialist qualifications for, and conferring them on, medical practitioners;
• continuing professional development for the medical profession; and
• assessment of overseas medical graduates who are applying for Australian specialist qualifications.

Our final view on whether the IGA delivers an acceptable model will depend on whether the issues we have identified in our submissions to government on the scheme are addressed satisfactorily.  It will also depend on how closely the final scheme reflects the existing arrangements, including the role of medical colleges in medical specialist arrangements, and truly protects the public interest.

Specialist Endorsement

The paper proposes to introduce a further arrangement for Ministerial approval of specialist endorsement.  Again, it contains no explicit recognition or incorporation of the role of the medical colleges in conferring specialist qualifications on medical practitioners, which is currently part of jurisdictional arrangements.

Instead, the Ministerial Council will be able to issue guidance to the medical board in relation to the criteria for the recognition of specialities under the scheme.  We believe this proposal goes beyond the agreement on the role of the Ministerial Council, as set out in the Intergovernmental Agreement (the IGA)¹, which was only to approve registration, practice, competency and accreditation standards.

It is inappropriate for, and there is absolutely no basis upon which, elected (and usually medically unqualified) politicians can “guide” the medical board on the criteria for the recognition of medical specialities.  We submit that a medical profession board with sufficient medical representation and expertise (as proposed in our submission on the first bill) will be well qualified to liaise with and take advice from the medical colleges on specialist categories and recognition. 

Further, government has already proposed a process under the scheme for the Ministerial Council to approve accreditation standards² for medical education and training courses, which will include specialist courses.  It is superfluous to overlay yet another Ministerial Council approval process for the “standards of qualifications”³  for the purposes of specialist endorsement. 

We note from the current proposal that government does not propose to establish a separate register for particular practitioners who have specialist qualifications. 

If the national medical register is to contain specialist endorsement, it should be on the basis of specialist qualifications conferred by Australian medical colleges, under Australian Medical Council (AMC) accredited training processes.  This would include medical practitioners who are on the pathway to Australian medical college fellowship, as well as college and AMC processes for recognising overseas specialist qualifications.  It would ensure that independent medical practice is undertaken only by practitioners who have specialist qualifications which are accredited by the AMC or whose training and experience have been assessed under the AMC process as substantially comparable to that of an Australian specialist and who are working under ‘oversight’ for a limited period prior to being invited to apply for fellowship of the relevant medical college.

Accordingly, we do not support any specialist endorsement for the medical practitioner register unless the national legislation for the scheme requires the national medical board to recognise the role of the medical colleges in conferring specialist qualifications on medical practitioners, through the arrangements outlined above.

Continuing competence requirements

In our submission on the proposed registration arrangements, we made extensive comments in relation to the proposals for continuing competence requirements.  We ask that our earlier submission be reviewed in the context of the proposals in this current paper.

Continuing competence is different to CPD.  It is unclear from the consultation papers on this issue exactly what government is proposing in this regard 

As we stated in our submission on the proposed registration arrangements, we cannot support the government using the introduction of the scheme to concurrently and unilaterally introduce wholesale and complex new continuing competence and CPD requirements.  The existing college CPD processes, which are discipline specific, (and defined by the college that has responsibility for the discipline) should be retained.  It is not appropriate to introduce generic profession CPD requirements as part of registration. 

If specialist endorsement were dependent upon fellowship of an Australian medical college as we propose, then the CPD requirements for specialist endorsement would automatically be met.

Accordingly, we ask government to suspend all of its proposals in relation to continuing competence and CPD requirements as part of the implementation of this scheme.  This aspect of the scheme cannot be implemented until government has developed full proposals, supported by a comprehensive discussion paper backed by scientific evidence, and undertake extensive consultation with the medical profession and the public.

Registration of specialists

The AMA and co-signatories are compelled to repeat our concerns about registration of people, who do not meet the requirements for general registration, in three of the limited registration categories listed:

• Specialist practice;
• Area of need; and
• Public interest.

We maintain that the medical board should not register unqualified people under these three categories if they do not meet the robust requirements and standards met by other registrants.  These concerns should apply across the health professions.  The absence in the consultation paper of any proposed requirement that people registered under these three categories be supervised, or that such registration be time limited, is evidence that government does not have patients’ interests at heart. 

It is entirely inappropriate to address short-term workforce supply problems by registering people who do not meet the registration requirements.  To do so will lead to the systematic lowering of standards, for all health professions and will have serious consequences for patient safety and quality care. 

Given the primary purpose of the scheme is to ensure the regulated health professions are suitably trained and qualified to provide safe and quality care, a person who does not meet the registration requirements for a health profession should not be registered. 

The AMA has consistently maintained that the solution to the medical workforce supply problems is not in allowing unqualified people to do the work of doctors.  Further, governments cannot tell the Australian people that this new scheme will protect them from unsafe health care providers while it proposes to allow unqualified people to be registered, let alone allowing them to practice without supervision and for unlimited periods of time.

Specialist practice
The AMA and the co-signatories cannot support a category of specialist practice that permits a person who does not meet the requirements for general registration, let alone specialist qualification, to practice independently in a specialty without restrictions and supervision. 

Given that current general medical registration is restricted to graduates of AMC accredited medical schools in Australia and New Zealand or to those international medical graduates who have obtained an AMC certificate, the AMA and co﷓signatories recognise that it may be necessary to establish the proposed limited category of registration for specialists. The registration of applicants in this category should be based on the advice of the relevant medical college, which may recommend a period of oversight, supervision, additional training or such other conditions as the college deems appropriate. Registrants in this category should be required to obtain Fellowship of the relevant medical college within a reasonable period

Areas of need
The proposal that Ministers will be able to designate areas of need in their jurisdictions, without any parliamentary, professional or public scrutiny is entirely inappropriate and further risks patient safety. 

Areas of need exist due to the conditions of the area and can be resolved by packages to attract and support qualified health practitioners.  While a non-qualified health practitioner may be an attractive budgetary option for a Health Minister and his or her health department, it is not an attractive health option for the people who live in that area.

However, if Health ministers insist on the power to designate areas of need as proposed in the consultation paper, it should only be in exceptional circumstances.  The legislation should require the relevant medical college to review the placement and its scope of practice as well as the individual candidate for the placement to ensure registration and the placement was appropriate.  Further, the designation of area of need status should be time limited and there should be clear, agreed criteria to ensure this is not overused or misused by state and territory governments.  It is clear from differing practice across the states at the moment that some jurisdictions are misusing the criteria and applying it even in metropolitan and city locations.

Public interest
The AMA and the co-signatories cannot identify a single circumstance under which a non-medically trained health professional should be registered as a medical practitioner in the public interest.  On behalf of the Australian public we cannot support this category of registration.  A scheme purporting to protect Australians would not include such a proposal. 

Scope of practice

The AMA and the co-signatories remain extremely concerned that the architecture of the scheme is being constructed in such a way that will allow patient safety and quality to be seriously compromised without the scrutiny of parliaments, the public or the profession.  We have already made these arguments in a number of our submissions.   

We await legislative assurance that each professional board will be required to consult with other boards on the expansion of scopes of practice, including prescribing rights.  Further, the legislation should require boards to consult under all circumstances.  If a board is consulted, and does not have an interest, then it can quickly communicate this to the relevant board.  It is not appropriate for one board to make a judgment that another board would not have an interest in the expansion of a scope of practice of a health profession.  In New Zealand, imprecise wording in the legislation along the lines proposed in the consultation paper has meant some boards have not consulted when they clearly should have.

The use of medical terms in specialist endorsement nomenclature
It is important that health professionals are prevented from misleading the public about their qualifications by the use of particular nomenclature.  In particular, some podiatrists have self-defined themselves as ‘podiatric surgeons’.  The Macquarie Dictionary defines surgeon as a medical practitioner who has undertaken postgraduate studies to specialise in surgery.  It is reasonable for the general public to assume a person using the title ‘podiatric surgeon’ is a medical practitioner.

The legislation should require boards to consult with the medical board on proposed titles for specialist endorsement, where the use of a medical term is proposed.

We are particularly concerned that some inappropriate practices will be entrenched and formalised as part of the implementation of the scheme and the proposed specialist endorsement arrangements.  Government should ensure that there is appropriate scrutiny of the training and scopes of practice of these groups before they are given any formal status under the new arrangements. 

The AMA and the co-signatories are of the view that, given the scope of practice of ‘podiatric surgeons’ an independent medical accreditation body with specific medical expertise should assess their courses.

Closing remarks

A number of the consultation papers state that in developing the national scheme legislation, Ministers will use as their guiding principles that:

• the safety of the public is paramount;
• high quality health care must be protected and advanced; and
• governments should be accountable and processes transparent.

The AMA and the co-signatories are not convinced that these guiding principles are being followed.

Dr Rosanna Capolingua
President
Australian Medical Association

Dr Chris Mitchell
President
Royal Australian College of General Practitioners

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

Dr Elizabeth Feeney
President
Australian Society of Anaesthetists

Dr Russell Bach
President
Australian Society of Ophthalmologists

Mr Howard Webster
President
Australian Society of Plastic Surgeons

John Buntine
President
Australian Association of Surgeons

Dr Andrew Pesce
Chair
National Association of Specialist Obstetricians and Gynecologists

Paul Kovac
Chairman
Australian and New Zealand Association of Urological Surgeons

Mr Pat Bary
President
Urological Society of Australia and New Zealand

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

Mr John Batten
President
Australian Orthopaedic Association

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Endnotes:

1. Clause 1.25(b) of Attachment A
2. Our previous submissions state we do not accept that it is appropriate for the Ministerial Council to approve the standards for accreditation of medical education and training courses.
3. Paragraph e on page 2 of the consultation paper.