Scope of practice review – the good, the bad and the ugly
After a year of discussion papers and countless workshops and meetings, the final report of the Scope of Practice Review was finally released in early November. The 194-page report contains 18 recommendations ranging from sensible, small reforms through to others I would politely refer to as ‘questionable’.
Dr Danielle McMullen
AMA President
Titled Unleashing the Potential of our Health Workforce, one of our major frustrations with this review from the start has been its title, and the assumption that all regulation is bad — that “leashes” are just turf protection, rather than patient protection.
Above all, there has been failure to answer the question of who should hold the leash.
We firmly believe that decisions about scope of practice and workforce should be made by independent, expert bodies, with robust processes — not politicians with knee-jerk reactions.
The AMA recognised the potential threats to patient care posed by the review and was strongly engaged in the review through three public submissions and a confidential submission to the draft final report.
We also provided a detailed literature review on the international evidence on non-medical prescribing. This showed autonomous prescribing is not as prevalent or successful as other stakeholders would have you believe.
We met with the lead reviewer, Professor Mark Cormack on many occasions, including inviting him to an AMA Federal Council meeting. We also discussed the review regularly with the GP colleges and other groups to ensure alignment in our positions.
In discussions with the federal government and the Department of Health and Aged Care, we have explained the risks with many of these recommendations, such as fragmented care. Sometimes I feel like a broken record in these meetings explaining that we need to invest in and support general practice, not eternally fund programs that only circumvent general practice, inevitably cost more, and are less efficient. We will continue to press this message.
I won’t detail all 18 recommendations, but I want to highlight a few that we are particularly concerned about and will continue to advocate against.
Recommendation 3 is to amend the Health Practitioner National Law to grant health ministers the power to give Ahpra and National Boards even greater policy direction on registration and accreditation functions.
We strongly oppose this on the principle that the regulation of health professionals exists to protect the community and ensure the highest standards of care for patients, and this is not something that politicians should be meddling in.
As we repeatedly highlighted in our submission, Australia has processes for reforms to scope of practice that are independent and consultative. The problem is these are regularly overridden by state and territory health ministers.
This leads to the absurd situation where scope of practice is now determined by political promises during election campaigns rather than independent bodies with expertise in relevant skills and standards.
Recommendation 6 is to introduce activity-based regulation of scope of practice. This recommendation demonstrates the review’s continued failure to understand that scope of practice is dynamic and contextual — a qualification is not the sole determinant of scope.
The determination of scope of practice should remain with the relevant National Boards. Proposals to expand scope should continue to proceed through the consultation process they currently undertake, with regulation impact statements conducted.
We continue to be very supportive of enhancing collaborative multidisciplinary care and ensuring all health professionals can work to their full breadth of scope in primary care, but this requires better funding models and improvements to the many reforms currently underway in general practice, such as MyMedicare. We need strong clinical governance to ensure that full scope is safe scope, and that we are truly working together.
Recommendation 12 is to introduce direct referrals from non-medical health professionals to non-GP specialists. We never understood where the suggestions in this list came from (for example, osteopaths referring to orthopaedic surgeons), but the AMA was not consulted.
As I highlighted directly to the reviewer, there have been many instances where an allied health professional has referred a patient to me with the expectation that I would then refer on to a non-GP specialist, only for the issue to be one I can easily manage as a GP. The issue is that our allied health colleagues do not understand the scope of a GP. This recommendation risks both the MBS budget and creating backlogs to non-GP specialists through unnecessary referrals.
This recommendation is frustrating because our health system already has the Medical Services Advisory Committee (MSAC), which can consider the value of this recommendation. The same goes for recommendation 11 to introduce bundled payments for maternity care. MSAC is an independent, expert body that appraises proposals for public funding for new medical services and provides advice to government based on an assessment of its comparative safety, clinical effectiveness and cost-effectiveness. We need to support and use the mechanisms that exist — not reinvent the wheel.
It's not entirely bad news — there are a couple of recommendations that we do like in the review, such as recommendation 7, the harmonisation of existing legislation and regulation, and recommendation 9, the establishment of an Independent Mechanism to provide evidence-based advice and recommendations on workforce models and scope of practice, provided it includes economic assessment.
It is important to note this is just a review. The government is yet to announce any actions in response to the report, and we are working to ensure any actions do not further fragment care or undermine our GPs. All our public submissions are available on the AMA website including our response to the final report.