Issue 5, December 2012
A recent invitation to address some of the newest members of the medical profession at their graduation ceremony has prompted me to think again about the core of medical practice. From Hippocrates to modern medical ethics, in medical school curricula and statements of graduate outcomes, through college vision and mission statements and training objectives and in Good Medical Practice, the Medical Board’s code of conduct for doctors in Australia, we try to find ways of expressing what it means to be a good doctor. What does the medical profession expect of its members? What does the community expect? And do these two views coincide? I think that mostly they do. At the core there are two basic elements: doctors must be competent and they must act in the best interests of their patients, rather than out of self-interest. There are many ways this can be elaborated and many shades of complexity can be added, but the basic premise is that a professional is someone who can be trusted because they will know what they are doing, will practise safely and act ethically.
A major challenge facing medical regulatory bodies around the world is how to ensure that doctors continue to practice safely and effectively long after they have graduated. With national registration came a requirement for each National Board to develop registration standards for recency of practice and continuing professional development (CPD). Practitioners must declare as they renew their registration that they meet these standards. In the next 12 months the Medical Board, in consultation with the profession and the community, will review the standards it set three years ago. We will also begin an audit process in which randomly selected practitioners will be required to provide evidence to support the declarations they make at renewal.
The Board is now beginning to consider whether this will be enough. Many jurisdictions around the world have begun more formal cyclical processes of revalidation for those who wish to continue to practise. The question facing the Board is, what is the appropriate response in Australia? Can we work with the Colleges, the Australian Medical Council, the AMA and other stakeholders to develop a CPD and recency of practice framework that is sufficiently robust? Or do we need to take on the bigger challenge and over the next few years devise an evidence-based, multifaceted, valid and cost-efficient way to ensure that every registered practitioner demonstrates that they continue to be able to meet the standards that both the profession and the community expect? It is time to begin that conversation.
Dr Joanna Flynn AM
Consultations and engagement
One of the ways the Board protects the public is by developing standards, codes and guidelines for the profession. With the other National Boards in the National Registration and Accreditation Scheme (the National Scheme), the Medical Board has begun preparations for reviewing the registration standards, guidelines and codes that were developed before the National Scheme began.
The review of the standards will draw on the best available evidence and address issues that have been identified in the first three years of the National Scheme.
We will be seeking feedback during the public consultation phases of the reviews. This is expected to occur over several stages, starting in 2013. When registration standards, guidelines and codes are common to all or most of the National Boards, the consultation phase will be coordinated across the professions. This staggered approach aims to minimise the impact on stakeholders, particularly those who are common across professions, and maximise opportunities for thoughtful feedback.
Further information about the reviews will be included in forthcoming communiqués of Board meetings and promoted on the Board’s website as they begin.
Review of registration standards, guidelines and codes
Registration standards are developed by the Board and must be approved by the Australian Health Workforce Ministerial Council (Ministerial Council), while the Board develops and approves codes and guidelines.
From 2013, the Board is due to review the registration standards below. The first five standards are mandatory under the Health Practitioner Regulation National Law, as in force in each state and territory (the National Law), and some are the same across the National Boards in the National Scheme. These are:
- the requirements for professional indemnity insurance
- matters to be considered in deciding whether an individual’s criminal history is relevant to the practice of medicine
- requirements for continuing professional development
- requirements about the English language skills necessary for an applicant for registration to be suitable for registration, and
- requirements in relation to the nature, extent, period and recency of any previous practice by applicants for registration.
The second set of standards is specific to medicine:
- Limited registration for postgraduate training or supervised practice
- Limited registration for area of need
- Limited registration for teaching or research, and
- Limited registration in the public interest.
The Board is also due to review:
- Good Medical Practice – a code of conduct for doctors in Australia
- Guidelines for mandatory notifications, and
- Guidelines for advertising of regulated health services.
Public consultation on social media policy
The Board will soon release a consultation paper on a draft social media policy, common to all National Boards.
A preliminary draft of the social media policy was released to some stakeholders for initial feedback, ahead of a wider public release. We aimed to ‘road test’ the initial draft for operational impact and major, unanticipated issues or concerns.
We were pleased to receive significant interest in the preliminary draft policy. We have reviewed the feedback and will use this to refine the next draft, which we expect to release for public consultation before the end of 2012. It will be published on the Board’s website under News.
The Australian Health Practitioner Regulation Agency (AHPRA), with the support of National Boards, has been progressively implementing a community engagement strategy aimed at increasing community awareness of, and participation in, the National Scheme. AHPRA has held community forums in most states and territories over the last six months, including a video-conference with community representatives from nine remote sites in Western Australia. A webinar (web-based seminar) will be scheduled for early 2013, for Australians living in rural and remote communities.
The forums provide an opportunity to meet members of the community, discuss issues about health practitioner regulation and learn where the community’s interest lies. AHPRA has also entered into a partnership with the Consumer Health Forum of Australia (CHF) to engage with health consumers and the broader community. CHF is the national peak body representing the interests of Australian healthcare consumers.
The AHPRA and CHF partnership aims to:
- raise community awareness of health practitioner regulation
- increase community access to information about health practitioner regulation
- facilitate community input into the development of standards, codes of practice, guidelines and policies for health practitioners, and
- increase transparency, particularly in relation to the processes in place for managing complaints about registered health practitioners.
Professions Reference Group
To establish dialogue and engage effectively with the professions included in the National Scheme, AHPRA, supported by the National Boards, established a Professions Reference Group. It is made up of representatives of the professional associations for the professions included in the National Scheme, with participation from AHPRA’s CEO and senior staff. The Australian Medical Association is a member of the Professions Reference Group. The group meets quarterly, including two face-to-face meetings each year. During 2012, responsibility for chairing meetings was rotated between professional associations, an arrangement that is expected to continue.
Meetings provide an opportunity for AHPRA to brief the professions about its work and for the professions to ask questions about emerging issues relevant to the regulation of their professions. The group also provides expert advice to AHPRA in developing a range of information for practitioners.
During the year, AHPRA consulted with the Professions Reference Group on the development of the service charter; and sought advice on the nature and scope of information it is developing for practitioners about the notifications process. By working with the group, AHPRA has also been able to establish a practitioner consultative group, made up of individual practitioners nominated by their professional association who are willing to provide feedback on proposals and systems improvements, to inform change and improve services ahead of large-scale implementation.
Starting the revalidation conversation in Australia
Internationally in medicine and medical regulation, there is discussion about revalidation for medical practitioners and how it can support patient safety. The International Association of Medical Regulatory Authorities (IAMRA), defines revalidation as ‘...the process by which doctors have to regularly show that they are up to date, and fit to practise medicine. This will mean that they are able to keep their license to practice. Sometimes called “Recertification.”’
The Board has decided to formally begin this conversation in Australia. It has not yet made any decisions or set a strategic course. It is committed to working with the profession, the community and other stakeholders about its approach, which will be informed through careful analysis of Australian data, our regulatory context and international research.
The Board expects to develop an initial discussion paper in 2013 and to consult widely with all interested stakeholders as the conversation about revalidation develops.
Review of accreditation arrangements
An important objective of the National Law is to facilitate the provision of high-quality education and training of health practitioners. The accreditation function is the primary way of achieving this. The National Law defines the respective roles of the Board and its appointed accreditation authority, the Australian Medical Council (AMC), in the accreditation of medical schools and medical specialist colleges.
Health Ministers first appointed the accreditation authorities for each of the 10 original professions in the National Scheme, before it began. The National Law requires National Boards to review the arrangements for the exercise of the accreditation functions by 30 June 2013.
Given that there are already arrangements for accreditation in place, the review process for all of the original 10 National Boards has begun with an assessment of the way each accreditation authority has performed its functions.
The Board invited the AMC to indicate whether they wish to continue exercising accreditation functions for the medical profession and the AMC have confirmed that they do. The AMC has provided a comprehensive report to the Board and after reviewing the report, and taking into account the experience with the AMC over the past two years, the Board has formed a preliminary view that the current arrangements for the accreditation function are satisfactory and should continue.
The Board consulted with stakeholders on the Board’s preliminary view of the accreditation arrangements. Stakeholder feedback indicates a high level of support for the AMC to continue exercising the accreditation function for the medical profession. The Board will consider the submissions before making a final decision.
The consultation documents are published on the Board’s website under News. Submissions will also be published shortly.
Transparency in the National Scheme
Panel decisions to be published
When investigating a notification, state and territory boards of the Medical Board of Australia may refer a medical practitioner to a health panel hearing, or a performance and professional standards panel hearing, consistent with the National Law.
In the Update of December 2011, the Board provided information about panel hearings: how they are conducted, what kinds of matters are referred and what is involved. This information is also published on the website under Notifications. Panel hearings are not open to the public and the name of the practitioner is not published.
The Board will publish de-identified summaries of panel hearings on its website, also under Notifications. It is a requirement of the National Law (section 232) to publish a record of adjudication decisions. Already, links to tribunal decisions about registered practitioners are published on the AHPRA website.
The Board believes it is in the public interest to publish this information about the work of the Board in protecting the public, in a way that does not identify individual practitioners but which clearly describes the issues practitioners face and how these are dealt with by the Board.
The Board encourages medical professionals to review these summaries, as part of their continuing education.
Health Profession Agreement published
The Board and AHPRA have now published the Health Profession Agreement that outlines the services that AHPRA will provide to the Board in 2012/13. Under the National Law, the Board and AHPRA work in partnership to implement the National Scheme, each with specific roles, powers and responsibilities set down in the National Law.
The guiding principles of the National Law require the National Scheme to operate in a ‘transparent, accountable, efficient, effective and fair way’; and for registration fees to be reasonable ‘having regard to the efficient and effective operation of the scheme’.
The Board and AHPRA are committed to transparent and accountable financial reporting. As AHPRA’s reporting capability strengthens, it will be able to publish more detailed information about each National Board’s financial operations and AHPRA’s performance. This complements the audited data and performance reporting included in each year’s annual report.
The Board is also committed to using practitioners’ registration fees wisely in regulating the profession in the public interest. The Medical Board of Australia’s Health Profession Agreement is available for review on the Board’s website.
One of the benefits of the National Scheme is that we now have national registers where we publish information about every registered health practitioner in Australia. For the first time, it is possible to produce accurate reports on the number of practitioners registered in each profession in Australia.
Earlier this year, the Board began publishing quarterly data profiling Australia’s medical workforce, including a number of statistical breakdowns about registrants. This data is published on the Board’s website under News and Statistics. Similar information about other health professions is also available on each Board’s website.
A snapshot from the September quarter reveals there are:
- 92,503 registered medical practitioners in Australia
- 53,086 practitioners hold specialist registration (most of these also hold general registration)
- there are about 6,000 international medical graduates with limited registration for postgraduate training, or supervised practice, or for area of need
- nearly 25,000 registered practitioners (25%) are aged 31–40 and there are nearly 24,000 over the age of 55, including 411 practitioners aged over 85, and
- 39% of the profession are women and 61% are men.
AHPRA and the National Boards submitted the 2012 annual report to Ministers by 30 September as required by the National Law. The report, publicly released on 1 November and published on the website, details the work of the National Boards and AHPRA in implementing the second year of the National Registration and Accreditation Scheme.
The annual report indicates:
- there were 4,001 notifications made about medical practitioners in 2012
- 3.5% of registered practitioners had a notification made about them
- 74% of notifications closed during the year were closed at assessment (for example, they did not progress to investigation, health or performance assessment or hearing)
- in 81% of matters referred for immediate action, the Board took some form of action on the practitioner’s registration
- there were 221 mandatory notifications made about medical practitioners, and
- 55% of mandatory notifications about medical practitioners relate to concerns about standards, 29% about impairment, nearly 8% about sexual misconduct, and close to 7% about alcohol or drugs.
All health practitioners registered under the National Law are required to comply with a range of registration standards. The registration standards are developed by each Board after wide-ranging consultation and must be approved by the Ministerial Council. All health practitioners must comply with the relevant registration standards for English language, criminal history, recency of practice, continuing professional development and professional indemnity insurance. The registration standards for medical practitioners are published on the Board’s website.
AHPRA is currently developing an auditing framework through the Practitioner Audit Project. As part of this large program of work, a pilot was conducted with the pharmacy profession earlier this year. A second phase of the pilot is being run at renewal this year with the optometry, pharmacy and chiropractic professions. In conjunction with the National Boards for each of these professions, the project steering committee will work to deliver a set of findings and recommendations that will eventually be used to develop a robust auditing framework that can be used across all 14 National Boards. This will be developed through analysis of data and process information from the both phases of the pilot.
This second phase began in October 2012 and will continue until early 2013. Practitioners from the three participating professions will be randomly selected when they apply to renew their registration for 2012-13. This will apply to both paper and online renewal applications.
Those selected to participate will be audited for compliance against their Board’s registration standards: criminal history, professional indemnity insurance, recency of practice and continuing professional development.
CPD audit working group
The Board recognises that audit of continuing professional development (CPD) for medical practitioners is likely to be complex. While the Board’s registration standard for CPD is straightforward, administrative implementation for audit is more difficult because the standard is tailored to the specific circumstances of individual registrants. For example, the requirements differ according to each practitioner’s type of registration and level of training and field of practice.
The Board has established a working group on audit of CPD for medical practitioners. In addition to internal stakeholders, the Board has also invited a representative from the Committee of Presidents of Medical Colleges (CPMC), the AMC and the AMA.
Intern registration standard approved
The Australian Health Workforce Ministerial Council has approved the Board’s registration standard for granting general registration to Australian and New Zealand medical graduates who have satisfactorily completed intern training. The new standard is published on the website under Registration standards and will apply to interns who start their intern year from 2014. This late start date is designed to give jurisdictions the opportunity to make any necessary changes to rotations during 2013.
The Board developed the standard after consultation with the profession and other stakeholders. It aims to achieve increased national consistency in the intern year. The standard provides for greater flexibility in training to enable training for increased numbers of medical graduates, while ensuring the intern year continues to meet their educational needs.
The standard moves away from ‘general medicine’ and ‘general surgery’ and requires experience in ‘medicine’ and ‘surgery’ and focuses on the type of experience obtained, explicitly allowing for part-time internships and allowing for part of the internship to be undertaken outside Australia. Eight weeks’ experience in ‘emergency medical care’ is also required, rather than in ‘emergency medicine’. This allows for increased flexibility in the way that experience in emergency medicine is obtained, and allows inclusion of some rural general practice settings covering a rural emergency department.
From 2014 (or 2013 where applicable), interns will be required to perform satisfactorily under supervision in the following terms:
- a term of at least eight weeks that provides experience in emergency medical care
- a term of at least 10 weeks that provides experience in medicine
- a term of at least 10 weeks that provides experience in surgery, and
- a range of other approved terms to make up 12 months (minimum of 47 weeks full-time equivalent service).
Terms must be accredited against approved accreditation standards for intern training.
Consultation on a proposed intern training framework
At the request of the Board, the AMC has undertaken work to complement and support the registration standard for granting general registration to Australian and New Zealand medical graduates on satisfactory completion of intern training. The AMC has developed draft documents that include:
- a set of global outcomes statements for the intern year that draws on the Australian Curriculum Framework for Junior Doctors and AMC graduate outcome statements for primary medical education
- a national framework for intern training accreditation process that harmonises different approaches to intern training accreditation across the country. This is necessary if we are to achieve greater national consistency, assure training standards nationally and provide an equitable basis for allocation of Board funds which support this accreditation process. This framework includes:
- national standards for intern training that build on existing state-based guidelines and standards
- guidelines on the experience that interns should obtain during medicine, surgery and emergency medical care terms (terms all interns must complete)
- a quality framework for intern training accreditation, which provides domains for assessment of intern training accreditation bodies in their intern training accreditation roles and a proposed process for assessment of their performance of these roles
- an outline of the roles and responsibilities in the framework, and
- a process for assessment and certification of interns as having met the requirements for granting general registration in the National Scheme. The aim is for an efficient and cost-effective national framework for assessment.
The AMC is currently consulting on these draft documents. They are available on the AMC website. The consultation closes on 17 December 2012. Stakeholders are encouraged to contribute to the consultation process.
Endorsement for acupuncture: registration standard approved
Medical practitioners who wish to use the title ‘acupuncturist’ must either have their registration endorsed for acupuncture by the Medical Board of Australia or be registered by the Chinese Medicine Board of Australia.
The Ministerial Council has now approved the Board’s registration standard for endorsement of registration for acupuncture. It enables the endorsement of registration for practitioners who have an approved qualification, and it also provides a mechanism to endorse the registration of practitioners who have been performing acupuncture recently and who have been undertaking relevant continuing professional development.
The standard now applies and is published on the Board’s website under Registration standards.
Accreditation standards for programs of study that lead to an endorsement for acupuncture
The Board asked the AMC to develop accreditation standards for programs of study in acupuncture that lead to an approved qualification. The AMC has now developed draft standards that:
- set broad objectives for training medical practitioners for acupuncture, and
- outline the educational processes and systems that will ensure the programs of study produce graduates capable of carrying out acupuncture for appropriate indications safely and effectively.
The AMC will consult widely about the draft accreditation standards for endorsement of medical registration. Interested stakeholders are encouraged to provide feedback. The accreditation standards will be published on the AMC’s website.
Consultation on international criminal history checks
The Board has consulted on international criminal history checks and with other National Boards, is now considering the feedback provided and appropriate future directions.
External health programs
Earlier in 2012 the Board consulted with the profession and the community in relation to the Board funding external health programs, at the request of Ministerial Council.
There are a number of programs in Australia that aim to support medical practitioners and medical students with health concerns. These programs vary considerably in the range of services that they offer and in the cost of providing them.
One such program, the Victorian Doctors Health Program (VDHP) was established by the previous Medical Practitioners Board of Victoria (MPBV) and the Australian Medical Association Victoria in 2001. The VDHP is a confidential service for doctors and medical students who have health concerns such as stress, mental health or substance use problems, or any other health issues. The VDHP does not provide direct medical care to participants but it does provide ongoing monitoring in particular circumstances.
The VDHP was funded by the MPBV from the registration fees of all registered medical practitioners and it continues to be funded from money that was committed by the previous Victorian Minister for Health from reserves of the Victorian Board, before the transition to the National Scheme. Funding had been committed until 30 June 2013.
Feedback from the consultation on external health programs found general support for the idea of external health programs, to complement the Board’s core focus on managing the health of impaired practitioners who may pose a serious risk to public safety. However, there was no consensus on the funding for such external health programs and very limited support for an increase in practitioners’ registration fees to enable them.
The Board continues to develop its position on, and explore options for, future funding for external health programs for doctors, while remaining focused on its role in managing impaired practitioners to protect public safety. As an interim measure, the Board has agreed to extend short-term funding of $350,000 to the VDHP for the 2013/14 financial year, while the Board determines a policy position.
The Board has not decided on the amount of funds, nor the range of services that it would fund into the future in establishing an equitable approach to external health services nationally. The Board is examining funding models for external health programs in the context of 2013 budget planning.
Successful renewal of medical registration
Medical registration expired on 30 September 2012 for medical practitioners holding general and/or specialist registration or non-practising registration.
In a successful renewal campaign, a total of 98% of practitioners renewed their registration, 1% opted out and the registration of 1% of practitioners lapsed.
Under the National Law, practitioners who do not renew their registration within one month of their registration expiry date must be removed from the Register of Medical Practitioners. Renewals received within one month of their registration expiry date incur an additional late fee, which reflects the cost of managing late renewals. More than 90% of registrants who were eligible to do so renewed online.
Medical practitioners who did not renew within one month of the expiry of their registration must apply for registration if they wish to continue to practise. They are not able to practise until the application for registration has been approved.
Grad online: transition from provisional to general registration for interns
AHPRA is asking all interns who are approaching the end of their internship to apply for their general registration early. Interns who hold provisional registration are encouraged to apply for general registration online.
Online renewals have been streamlined and have been made easier to complete. Applicants who have provided certain information under the National Scheme do not need to provide duplicate information.
We are also working with hospitals that train interns, encouraging them to provide certificates of satisfactory completion of the intern year directly to AHPRA and reduce the administrative burden for applicants.