Lessons Learned, Changes Made - PowerPoint Presentation

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Lessons Learned, Changes Made- a new era in Australia

Dr Joanna Flynn

Chair

Medical Board of AustraliaSlide2

Outline

Australia past and present

The sorry saga of Dr Patel

The new era in health professions regulation

Where did it come from?

What is it?

How does it work?

Enduring challenges in medical regulation in AustraliaSlide3

Brief history of Australia

First Australians arrived > 50,000 years ago

Terra Australis – imagined by Aristotle, seen by Portuguese, Spanish, French, Dutch 16

th

- 18

th

C

Australia claimed for Britain by James Cook 1770

British Penal Colonies 1787-1868;160,000 convicts

Free settlers from 1790’s

Gold rush, farming, mining

1901 Federation of six states, population 4M Slide4

Australia today

Total population 22.5 million, urban 89%

25% resident population born overseas

UK 23%

NZ10%

China 6%

Italy 5%

Vietnam 4%

India 3%

Median Age 37Slide5
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Historical context of regulation

Council of Medical Examiners, Van Diemen’s Land (Tasmania)

NSW 1838 then other states and territories (GMC UK 1858)

Powers initially limited to registration, later included investigation and disciplinary processes

More recently – impairment, performance, codes, guidance

Changing from

Medical Acts

to cross profession legislation e.g.

Health Professions Registration Act 2005, VictoriaSlide7

Changes already occurring

Increasing community involvement

Public access to information

About those on the register

About Board processes and outcomes

Separation of Powers

More oversight and scrutiny

Greater accountability Slide8

Is medical regulation failing?

- the sorry saga of Dr PatelSlide9
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Timeline

April 2003: starts work at Bundaberg Hospital

Jun 2003: Nurse Toni Hoffman first raises concerns

In 24 months over 20 complaints by staff/patients

Feb 2005: Qld Health begins investigation

Mar 2005: concerns raised in Parliament

April 2005: Patel resigns, flies back to Oregon

April 2005: media reveals US historySlide12

Timeline (2)

April 2005: Premier announces Morris inquiry

Sep 2005: Morris enquiry axed by Supreme Court over ostensible bias against 2 Qld Health employees

Sep 2005: Davies inquiry reported Nov 2005

Nov 2006: warrants issued for Patel’s arrest, 16 charges include manslaughter, GBH, fraud

Jul 2008: Patel extradited to Brisbane

Feb 2009: committal hearingSlide13

Timeline (3)

Jun 2010: jury finds Patel guilty three counts of manslaughter, one count of GBH after 15 week trial

July 2010: sentenced to seven years jail

Aug 2010: Patel appeals against conviction and sentence and Attorney General appeals against leniency of sentence

Nov 2010: Patel’s appeal scheduled

Fraud and other proceedings outstanding

Currently in jailSlide14

Evidence to Commission of Inquiry re Patel

“Dr Patel’s results were not ten times worse than one would expect; they were one hundred times worse”

unacceptable care contributed to 13 deaths

unacceptable care may have contributed to 4 deaths

poor care contributed or may have contributed to adverse outcome in 31 surviving patients

“Incompetent”Slide15

Commission of Inquiryfindings re Medical Board

Dr Patel was registered because

negligent omission by the Medical Board to advert to a notation on Dr Patel’s Certificate of Licensure from Oregon

negligent failure by Board to make inquiries about Dr Patel’s past practice in the United States

negligent failure by Medical Board to assess his qualification and experience suitable for positionSlide16

Patel’s Registration in Qld

Feb 2003: registered to fill area of need as senior medical officer Bundaberg Base Hospital having declared he had no current suspension or cancellation and no history of restrictions imposed by any registration authority

Jan 2004: further registration granted as Director of Surgery

Feb 2005: further application deferred on basis of concerns raised in Bundaberg

April 2005: review by Board revealed orders of Oregon BME, NY Office of ProfessionsSlide17

Known disciplinary record

1984: NY BPMC disciplined Dr Patel during his residency for entering histories without examining patients, failure in record keeping, harassing a patient for cooperating with NY investigation: six month license suspension with stay, 3 years probation, fines

1989: Registered in Oregon

2000: BME Oregon disciplined Patel for gross or repeated acts of negligence and unprofessional conduct and placed restrictionsSlide18

So what did we learn?

Review the integrity of registration processes

Identity, primary source verification

Question gaps in CV

10 yr history from previous registration bodies

Criminal history checking

Pre-employment assessment - suitability for role

Supervision processes and monitoring

Responsiveness to concernsMandatory reportingSlide19

A new era in health professions regulation in AustraliaSlide20

The new scheme - NRAS

National registration and accreditation scheme (NRAS) for

The regulation of health practitioners

The registration of students undertaking

Programs of study that provide a qualification for registration in a health profession; or

Clinical training in a health profession Slide21

Where NRAS came from…

Concerns about health workforce shortages, rigidity

Concerns about adequacy of regulatory processes

Feb 06 - Productivity Commission report-

Australia’s Health Workforce –

recommended single cross profession accreditation and registration boards

July 06 - COAG announced NRAS – to start July 08 “to facilitate workforce mobility; improve safety and quality; reduce red tape; simplify and improve consistency”

March 08 - COAG signed Intergovernmental Agreement with implementation date 1 July 2010Slide22

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Before July ‘10

Eight States and Territories

> 85 health profession boards

66 Acts of Parliament

Since July ‘10

One national scheme (+WA)

10 health profession boards (+WA)

Nationally consistent legislationSlide23

Legislation…

Act A –

The Health Practitioner Regulation (Administrative Arrangements) National Law Act 2008 (Queensland)

Act B –

Health Practitioner Regulation National Law Act 2009

- Full provisions for operation of the scheme, commenced 1 July 2010

Acts C – Adoption and Consequential Bills in each jurisdiction progressively in the past 12 monthsSlide24

Guiding principles…

national scheme to operate in

transparent

,

accountable

,

efficient

,

effective and fair wayregistration fees to be reasonable (having regard to the efficient and effective operation of the scheme)restrictions on practice to be imposed only if necessary to ensure health services provided safely and of appropriate qualitySlide25

Objectives…

Provide for

protection of the public

by ensuring that only practitioners who are suitably trained and qualified to practice in a competent and ethical manner are registered

Facilitate

workforce mobility

across Australia

Facilitate provision of

high quality education and training of health practitioners Facilitate rigorous and responsive assessment of overseas practitionersFacilitate access to services in the public interestEnable continuous development of a flexible, responsive and sustainable Australian health workforce and enable innovation in education and service deliverySlide26

Structure…

Ministerial Council

Advisory Council

National Boards

Agency

Management

Committee

National

Committees

State/ Territory/ Regional

Boards

National Office

State and Territory

Offices

Support

Support

Support

Accreditation

Authorities

Contract

AdviceSlide27

Health Professions…

July 2010

chiropractors

dental care (including dentists, dental hygienists, dental prosthetists & dental therapists),

medical practitioners

nurses and midwives

optometrists

osteopaths

pharmacistsphysiotherapistspodiatristspsychologists July 2012

Aboriginal and Torres Strait Islander health practitionersChinese medicine practitionersmedical radiation practitionersoccupational therapists Slide28

NSW…

Registration will be national and registration decisions will be made by National Board

Performance, health and conduct will be managed under NSW scheme in a co-regulatory model with Health Care Complaints Commission (HCC)

HCC retains role as independent investigator and prosecutorSlide29

Role of National boards…

Set national standards, codes and guidelines

Determine requirements for registration

Approve accredited programs of study

Oversee assessment of overseas trained practitioners

Oversee receipt and follow-up of notifications on health, performance and conduct

Maintain registers (with AHPRA)

Delegate powers to staff, committees

Set registration fees and develop Health Profession Agreement with AHPRASlide30

Role of AHPRA…

…all functions in line with the objectives and guiding principles of the scheme

…provide support and administration services to National Boards and committees, through one organisation with a National office and State/Territory offices

Health Profession Agreements with National Boards:

employ staff

manage contracts

own and manage propertySlide31

Key features of national law…

Registration standards

Criminal history

English language proficiency

Recency of practice

Mandatory continuing professional development

Mandatory professional indemnity insurance

Mandatory Reporting of notifiable conduct

Student registrationIndependent accreditation functions Australian Medical Council appointed for medicineSlide32

Key features …

Boards appointed by Ministerial Council

Two thirds practitioners, one third community

Members from each jurisdiction with

Initial membership drawn from existing state and territory medical Boards

Previous medical boards now committees of national board

Chair of each Board a practitioner member

National registration fee for each profession

Self-funded from registration fees, no subsidiesNo cross profession subsidisationSlide33

Mandatory notifications…

Practitioners and employers must report a registrant who they reasonably believe has engaged in notifiable conduct (some exceptions)

Belief formed through the practice of the profession

Not limited to notifications in same profession as practitioner

Notifiable conduct is:

practising while intoxicated by drugs or alcohol

engaging in sexual misconduct in connection with professional practice

placing the public at risk of substantial harm through a physical or mental impairment affecting the person’s capacity to practice

placing the public at risk of harm through a significant departure from accepted professional standardsSlide34

Notifications…Act also allows for voluntary notifications

Protection from liability for persons making notifications or providing information in good faithSlide35

Conditions…

Conditions of registration will be shown on the Register (publicly accessible)

Where health conditions are in place note on Register that the practitioner is subject to health conditions – details of conditions not providedSlide36

Progress so far…

All states except WA up and running

National on line register

Code of conduct

Good Medical Practice

endorsed

Registration Standards approved by Ministers

Transition ~ 500,000 registrants to the National Law

Health Professions AgreementsAgreements with Accreditation AgenciesMandatory reporting guidelines issuedAdvertising guidelines issuedSlide37

Registration in new scheme

Registration

type/subtype

Number

General only

24,236

General & Specialist

38,026

Specialist only5,594LimitedPublic interest – occasional practice1,410

Teaching/research185Area of need2,069Public interest494Postgraduate training3,442Non-practising2,475Provisional2,180Slide38

Noticeable Differences

Registration fees

Requirements for CPD, Recency, PII

Specialist registration

Identity – AHPRA, MBA

Communication and relationships

Policies and procedures

Outcomes?Slide39

Where to from here?Slide40

Medicine has perennial moral problems, two of which are particularly serious in the present age: insensitivity to suffering and abuse of power

Ian McWhinney

Patient-Centered Medicine 1995Slide41

Professional Responsibilities of Medicine

All doctors must accept

seek trust and deserve it

as their moral law

Patients and society rely on medicine to be trustworthy

Patients do trust because a history of doctors acting for their patients’ good has made medicine trustworthy

Rosamond Rhodes

The Blackwell Guide to Medical Ethics 2007Slide42

Some of the real problems

Workforce shortage and maldistibution

Burnout and low morale

Safety, quality and appropriateness of services

Distortions driven by payment systems

Gap in expectations

of healthcare

of regulationSlide43

Challenges in accreditation

Should Australia have a licensing assessment for all?

The medical education continuum – linking it up

The burden of accreditation

Emerging areas of practice & roles (e.g. cosmetic medicine, physician assistants)

Very large increase in numbers of medical students

FundingSlide44

Biggest issues – plus ça change

Assessment and supervision of IMGs

Proportionate and timely responses

Separating big issues/ less serious/ non issues

Frivolous or vexatious – both doctors and public

Should system be entirely self-funded?

The confidence of the public and the professionSlide45

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Enduring challenges…

Credibility

“one bad apple”

greater risk in national scheme?

The view that any doctor is better than no doctor

Perceptions: old boys club, out of touch, too punitive, too soft or focussing on wrong issues

Ensuring ongoing competence and performanceSlide47

The future…

Transparent, accountable, efficient, effective, fair regulation

Respected source of advice and guidance

Responsive, adaptive, open, outward facing

Engaging with profession and community

Financially sound with reasonable fees

A framework to maintain trust