The AMA did not oppose the principle of a national, as distinct from state-based, system of registering medical professionals. In fact, it supported it. What it complained about was that so much of the influence on standards would be exerted by bureaucrats – people who in the AMA’s view would not know the difference between a speculum and a sphygmomanometer.
A national registration system had been considered in 2001 by federal and state health ministers and then deferred at the request of the AMA. It had argued that, though it supported the principle, the version that the Ministers were considering had massive deficiencies, not the least of them being that it proposed loading bureaucratic requirements on to doctors without improving patient safety. The matter seemed to have ended there. But, in 2006, the Productivity Commission (which had been asked to report generally on health workforce issues) resurrected the idea and proposed ways to do it that were accepted later in the year by Council of Australian Governments (COAG).
The Commission had proposed a single national registration and accreditation system (NRAS) in which a national accreditation board (whose membership would “reflect the public interest generally rather than represent the interests of particular stakeholders”) would police standards and a single national registration board would handle registration to practise. COAG preferred a slightly different version: a single cross-profession national registration board, primarily to manage policing and disciplinary matters, which would be set up in 2008 in parallel with a national accreditation system. It would apply to the nine occupational groups that were already subject to statutory registration: the medical, dental and nursing/midwifery professions, optometry, osteopathy, pharmacy, physiotherapy and psychology. COAG did accept the Commission’s proposal, though, that membership of the accreditation board should be “structured to reflect the public interest generally rather than represent the interests of particular stakeholders”, and it directed “senior officials” to oversee implementation “in consultation with relevant stakeholders” and report back to COAG by the end of 2006. Template enabling legislation would be developed by the Queensland Government.
The AMA was severely critical of NRAS. It supported national accreditation and registration systems for doctors, Federal President Dr Mukesh Haikerwal said, “but we are opposed to systems that bundle doctors in with everybody else under the heading of ‘health professionals’, but that’s what COAG has done. It would be a world first in health to have a brand new huge bureaucracy that has a positive impact in delivering quality healthcare. This is dumbing down and de-medicalising the health system and it erodes quality.” The Government was heading for an extremely difficult election; an angry and threatened health workforce was the last thing it needed. The AMA persuaded Prime Minister Howard that NRAS should be deferred.
Early in 2008, COAG presented some significant goodies to the health system, for which the AMA had been agitating: an immediate $1 billion allocation to public hospitals, for example, and agreement that the Australian Health Agreement funding formula – which had been the cause of sustained game-blaming, leading to the States having to assume a greater share of funding – should move “to a proper long-term share of Commonwealth funding for public hospitals”. But it also gave life back to NRAS, with all its bureaucratic superstructure and oversight that the AMA had fought two years before. The AMA was outraged: NRAS would “empower Ministers to decide on the accreditation of training for health professionals”, Dr Capolingua said, and on “what is required to become a doctor, a dentist or a nurse”. As the details of the scheme became clearer, through the progress of the enabling legislation and a series of discussion papers and other publications by COAG, the AMA put forward seven formal submissions on the scheme. It organised a consciousness-raising campaign among allied professions about the deficiencies of the scheme. The Government persisted, however, and the Health Practitioner Regulation (Administrative Arrangements) National Law Act 2008, enabled NRAS to start operating in 2008. By then, other fields of battle were opening up and relations were turning decidedly sour between the Rudd Government and the AMA over other elements of health policy.
When the Government drew up its infrastructure stimulus package to deal with the global financial crisis of 2007-09, the AMA attacked its “inexplicable exclusion” of health. This “singular failure of government”, as Dr Capolingua described it, ignored the potential of the sector for providing “the same immediate benefits to the economy as other infrastructure projects, stimulating employment and supporting business but with the added bonus of expanding the nation’s capacity to deal with tough new economic circumstances”.
Battle was joined again when the AMA fought “another piece of bureaucratically-driven” legislation (the Health Insurance Amendment (Compliance) Bill), which enabled the Increased MBS Compliance Audits Initiative announced in the 2008-09 Budget, which (among other things) increased penalties on doctors for incorrect Medicare billing and permitted Medicare to expand its audit program by giving it access to medical records so as to verify billing by doctors. A formal submission to a Senate committee on the Bill explained the AMA’s fundamental concerns about how the proposal would compromise “the central ethic in medical practice which preserves the privacy of the doctor-patient relationship” and the unnecessary additional red tape it would impose on doctors. In her statement to the committee when introducing the AMA submission, Dr Capolingua said that the Bill sought “to strip patients of their privacy on a whim” through what was no more than a fishing expedition, “a huge expensive net being dragged through the profession but, more importantly, through the intimate details of our patients, in the hope that it will dredge up some mistakes and, fingers crossed, perhaps a few real areas of concern”. At the annual AMA Parliamentary Dinner, she told the politicians and bureaucrats who were there that she stood with doctors who said that they would go to jail rather than divulge personal patient information, which was what Medicare was demanding.