National Registration and Accreditation

Intergovernmental Agreement for a National Registration and Accreditation Scheme for the Health Professions (the scheme)

The purpose of this document is to inform all doctors about the scheme agreed by the Council of Australian Governments (COAG) on 26 March 2008.

COAG has been developing a scheme for National Registration and Accreditation for some two years.  The AMA has urged governments to implement a rational and effective registration system: one that would facilitate the transfer of medical practitioners’ registration to enable movement across the country.  COAG has incorporated the regulation of both registration and accreditation into their scheme. This was not part of the AMA proposals.

Throughout the COAG process, the AMA has consistently engaged and made clear its significant concerns with regard to the efficiency and complexity of the proposed system and its extension into possible control of medical practice and competency standards and accreditation of medical education and training courses.  What has evolved appears to be a complex bureaucratic arrangement that is cumbersome and expensive.  It places the setting of standards for the medical profession into a political and bureaucratic regulatory environment.  The scheme is underpinned by a workforce reform agenda.

The Intergovernmental Agreement (the IGA) sets out the structure and functions of the scheme.  The IGA can be accessed at:

http://www.coag.gov.au/meetings/260308/docs/iga_health_workforce.rtf

A snapshot of the scheme, with references to the relevant clauses in the IGA appears at the end of this document.

On 26 March 2008, the AMA and the Committee of Presidents of Medical Colleges (CPMC) presented the Prime Minister with five principles for medical registration and accreditation:

1. National recognition of registration;
2. A publicly-available national register;
3. Uniform registration and disciplinary functions by local boards;
4. Independent accreditation of medical education and training; and
5. Professional standards set by independent bodies.

The signing of the IGA has brought focus on three critical issues for the medical profession: dealing with “rogue” doctors, medical registration and medical standards.

“Rogue” doctors
We believe there is an ethical obligation on medical practitioners to report suspected misconduct.  The AMA is always appalled by acts of gross misconduct by individual doctors.  We will work with governments to ensure that strong action is taken against the very small number of doctors who cause their patients harm.  To do this requires a different approach outside the scheme.  The answer to this particular issue does not lie in registration arrangements per se.

The AMA is concerned that the complex structure of the proposal in the IGA may compromise the ability to respond rapidly to cases of  “rogue” doctors and we would be keen to work towards implementing a system which improves effective reporting and action.

Registration
The AMA supports national recognition of registration for the medical profession.  The AMA wants harmonised registration and a public national register.  The public must have registered, safe, quality doctors who can work when and where they are needed.

Medical standards
Accreditation of medical education and training in Australia is founded in its independence from government, the medical schools and the medical profession.  Australia’s current framework meets international guidelines¹.   The AMA has consistently supported and reinforced the independence of this framework during the debate of the past two years on the scheme.

The COAG scheme removes the independence of accreditation of medical education and training by putting the approval of accreditation standards in the hands of Health Ministers.

Medical Colleges determine medical practice and competency standards.  Accredited medical specialty education and training programs ensure that doctors acquire the requisite knowledge, skills, competencies and professional qualities to undertake unsupervised comprehensive medical practice.

Under the COAG scheme, Health Ministers will approve medical practice and competency standards and they will have to take advice from the Australian Health Workforce Advisory Council².

The COAG scheme
The scheme will merge the registration and accreditation functions for all health professions into a single national agency.  This agency will report to the Australian Health Workforce Ministerial Council (AHWMC), which will approve registration, practice, competency and accreditation standards and continuing professional development requirements³.  The AHWMC must take advice from a workforce advisory council on any matters that it sees fit⁴.  There is no guarantee the workforce advisory council will have medical representation.

What role will this advisory council have in the setting of medical standards?

The AMA is concerned that medical practice and competency standards and accreditation standards for medical education and training will be determined on the basis of advice that has little or no medical input.

The “National Registration and Accreditation Scheme” is not just about registration and accreditation.  There is a much broader agenda for workforce reform and regulation.  The scheme will operate under the principle that the practice of a profession will only be restricted where the benefits of the restriction outweigh the costs⁵.  What parameters or criteria will be used to determine this cost benefit analysis?  Patient safety and quality of care must be taken into account.

Will the scheme result in the blending of medical practitioner standards into standards for other health practitioners as a means to satisfying workforce shortages?   This will threaten to lower the standards for the delivery of health care in Australia and risk the safety and quality of that care.

COAG would need to explain this broader agenda to the Australian public. 

Medical Boards in each jurisdiction will cease to exist⁶.  The Australian Medical Council (AMC) will cease to exist in its current configuration⁷ and its long-term existence is threatened in the three-year review⁸.  From the framework described in the IGA, in the transition period, the AHWMC will assign accreditation functions to existing accreditation bodies, but with the loss of the independence of their function.  There is no guarantee the AMC will be assigned the function of accrediting medical education and training courses.

There is no provision in the IGA for assigning the function of developing medical practice and competency standards to existing bodies currently performing that function.  There is no guarantee that the Medical Colleges will have any role in setting medical practice and competency standards.

As a precursor to COAG signing the IGA, the Federal Minister for Health and Ageing argued a national scheme would ensure higher standards of patient care and prevent rogue doctors from slipping through the cracks⁹. 

The AMA does not believe that this particular issue is addressed by the new registration arrangements, nor that existing medical registration arrangements contributed to recent cases.

If restrictions on practice are not observed, any system (local or national) will fail.  How will the COAG scheme ensure that doctors with restrictions on practice comply?  The AMA is concerned that a more centralised national scheme may widen the cracks.

A different approach is required to deal with “rogue” doctors.

The public may be better protected from “rogue” doctors if a legal mechanism is implemented that encourages reporting through provisions that protect medical practitioners who report doctors who may be guilty of gross misconduct or gross negligence and for those reports to be investigated quickly and judiciously.

Such a system could be implemented with minimal bureaucracy, to provide a rapid response to incidents of “rogue” doctors.  The measure taken by the NSW Government appears to address this issue.

Under the scheme, State and Territory entities (eg State Administrative Tribunals) will hear the serious disciplinary matters and appeals on the less serious matters on referral from the national entities.  Is that relationship legally possible?  The AMA is concerned that determinations on serious disciplinary matters may not withstand legal challenge.

Will the scheme achieve its objectives?
It is disappointing that there has been no explanation by Australian governments about the merits of the scheme.  While it is based on recommendations in the Productivity Commission report Australia’s Health Workforce December 2005, there has been no critical evaluation of those recommendations and their impact on health outcomes.

The IGA provides the following objectives for the scheme¹⁰:

• Protection of the public;
• Workforce mobility;
• Reduction of red tape;
• High-quality education and training;
• Rigorous assessment of overseas trained practitioners;
• Promotion of access to health services;
• A flexible, responsive and sustainable workforce; and
• Innovation in education and service delivery.

The AMA supports the first five of these objectives in principle, although there are some questions around how the scheme will achieve them.  The AMA notes that existing registration and accreditation arrangements already deliver these objectives.

Protection of the Public
Patient safety is paramount, and demonstrably the most important objective behind registration and accreditation processes.  Will the elected politicians and the bureaucracy who intend to develop and set the standards put high quality outcomes and patient protection before workforce considerations?

The AMA is concerned that a workforce reform agenda and/or a desire to place practitioners to fill workforce shortages will take precedence.

Workforce mobility
A flexible, responsive and sustainable workforce must not compromise standards. How will the objective of workforce mobility be balanced against ensuring Australians have equal access to high standards of medical care?  The AMA is concerned that registration standards will be lowered to allow jurisdictions to place medical practitioners in areas of workforce shortages.

Reducing Red Tape
The reduction in red tape is not apparent from the IGA, particularly in light of the additional layers of bureaucracy within the scheme.  The framework described will be more expensive to maintain than the medical registration and accreditation systems in place now.  How will the scheme reduce red tape?  The AMA is concerned that the additional layers of bureaucracy will add to red tape.

The scheme will be self-funding¹¹, with the costs of the scheme being passed on to health professions¹².  The AHWMC can intervene on budgets and fees¹³.  Will medical practitioners be paying higher registration and accreditation fees to support the scheme?  If so, this will mean the costs of medical practice will increase and inevitably these costs will be passed on to consumers.

Rigorous assessment of overseas trained practitioners
It is not clear from the IGA whether the assessment of overseas trained practitioners will be more or less rigorous than Australian trained practitioners.  Neither is it clear whether overseas trained practitioners will have less restriction on their practice when they are being placed in an area of workforce shortage.

Quality of education and training
Australia prides itself on having a world-class health system.  This is because the quality of Australian medical education and training is world-class.  Australian trained doctors are highly regarded.  This has been achieved through the activities of the independent, expert body for accrediting medical education and training, the AMC.

The AMA asks whether the standing of our training is put at risk with the dismantling of current arrangements and making the AMC dependent under a National Medical Board, a National Agency and an Australian Health Workforce Ministerial Council?

What is the reason to dismantle the independent processes and replace them with a government body that also has the responsibility for the accreditation of education and training for eight other health professionals?

Both actions fall short of the international standards.  Accreditation of medical education and training in Australia must continue to meet international guidelines. 

Will putting the accreditation of medical education and training in the hands of elected politicians and the bureacracy improve the quality of medical education and training?

As already noted, the IGA is completely silent on the role of Medical Colleges continuing to develop medical practice and competency standards. 

What is the future of the Medical Colleges?  The AMA is concerned that the Medical Colleges will be relegated to an education and training delivery role only.  Moreover, the AMA is concerned that the Medical Colleges could be completely sidelined as has become the scenario in Britain.

Under the COAG scheme, the National Medical Profession Board will manage the development of practice and competency standards and continuing professional development requirements¹⁴, yet there is no provision for how these standards will be developed. 

Local and national committees will be established to undertake functions in relation to registration, investigation of conduct, competence or impairment matters, conduct of disciplinary hearings, course of study accreditation and assessment of overseas trained practitioners¹⁵.  Yet no provision has been made for an organisation to set medical practice and competency standards.  Which bodies will undertake this function?

The AMA is concerned that the role of the Medical Colleges has been lost in the development of the COAG scheme.   

The remaining objectives
In respect of the last three stated objectives, the AMA has the following questions:

• To what extent, and through what mechanism, will registration and accreditation processes promote access to health services?
• Can a flexible, responsive and sustainable workforce be achieved without compromising the high standards we have now?
• Will innovation in education and service delivery be shown to work effectively and without risk to patients before they are incorporated into standards?

Conclusion
As it stands, the IGA has merged registration, accreditation and workforce planning. There are many questions produced by the IGA’s framework.  As previously stated the AMA is not calling for the status quo with registration and certainly will support better processes to identify and deal with “rogue” doctors.

The AMA also recognises the demand pressures on the health system and the consequence challenges for the workforce. 

The demand for health care in Australia continues to rise.  The population is ageing and the prevalence of chronic disease and disability is increasing.  With demand exceeding supply, governments will seek policies to correct the imbalance.  COAG has sought to blend registration and accreditation, with the effect of lowering the health professional standards to address the demand for supply.

This approach is based around the idea that the different health professions are close substitutes for each other.  This is not the case at all.  On the contrary, the various health professions have roles and responsibilities that are complementary to each other.  High quality health care requires very strong teamwork with each profession enabled to do what they do best.  Doctors have a very sharp appreciation of the impact on health outcomes that can be achieved through the skills and efforts of para-medical health professionals.

Does the scheme seek to address medical shortages by allowing lesser-trained professionals to fill medical workforce shortages?  As it is written, the AMA can only assume the predominant workforce reform agenda will facilitate other health professionals providing service for which they are inadequately trained.

When Australians get sick they need to and want to see a doctor.  The introduction of the scheme must not take priority over the introduction of policies to address the shortage of Australian trained doctors.

Australia needs strategies to:

• Encourage Australian trained doctors to remain in the workforce;
• Provide adequate funding for training places for the number of medical students about to graduate; and
• Undertake proper and rigorous workforce planning to avoid the over and under correction policies of the past.

As medical professionals there is no justification for an abrogation of clinical responsibility.  Therefore, when addressing health workforce planning concerns the AMA will always engage solutions from the stance that clinical leadership involves delegation of tasks and the supervision of clinical outcomes.  This is already a proven and prudent professional duty.  Multidisciplinary teams and collaborative working partnerships already characterise contemporary health services.  The AMA will embrace any progressive planning challenges based on these principles.

The IGA is in the implementation phase.  The Federal Health Minister has accepted the AMA’s offer to be actively involved in the detail and implementation of administrative arrangements so that medical standards can be safeguarded and doctors can have a rational process of registration.

The AMA is determined to work with governments on implementation to resolve our questions and the others that will arise.

April 2008

Snapshot of the scheme

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Endnotes:

1.  The World Health Organisation and the World Federation for Medical Education Guidelines for Accreditation of Basic Medical Education.  Geneva/Copenhagen 2005
2.  Paragraph 1.2 of Attachment A to the IGA
3.  Subclause 7.5(g) of the IGA
4.  Subparagraph 1.8(c) of Attachment A
5.  Subclause 5.4(c)
6.  Clause 6.5
7.  Paragraph 1.34 of Attachment A
8.  Paragraph 1.36 of Attachment A
9.  Sydney Morning Herald 25 March 2008
10. Clause 5.3
11. Clause 12.3
12. Clause 12.1
13. Subclause 7.5(i)
14. Subparagraph 1.25(b) of Attachment A
15. Subparagraph 1.25(a) of Attachment A