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02 Apr 2015

By Dr Stephen Parnis, AMA Vice President

No-one likes being the subject of a complaint.

For conscientious practitioners, it can be extraordinarily stressful and unpleasant.

For years the AMA has been active in working with the regulator to improve the operation of the national registration and accreditation scheme for the health professions. 

Since the National Scheme’s commencement on 1 July 2010, the serving Federal AMA President has met at least twice a year with Dr Joanna Flynn, Chair of the Medical Board of Australia (the Board) and Martin Fletcher, CEO of the Australian Health Practitioner Regulation Agency (AHPRA).

The AMA has used these meetings to have honest and open discussions about how the scheme is working and its future directions, and the Board and AHPRA have been responsive to our feedback.

The AMA has always maintained a keen interest in the cost of the scheme.

We have been able to provide considered input into the development of, and revisions to, the registration standards and other guidance documents produced by the Board to regulate the professional practice of medicine.

The AMA shares the Board’s objective to protect the public by using minimal regulatory force to manage the risk posed by the practice of some practitioners. Punishment is not part of its goal.

In preparing its submission to an independent review of the scheme, the AMA last year surveyed members about their experiences.

The overwhelming response was that, after initial teething problems, the registration process has bedded down - though the experience with investigations of notifications was problematic. Members commented that:

  • there was a lack of clarity and transparency regarding the process and decision-making;
  • there was ineffective and inefficient vetting of complaints and notifications;
  • investigation processes were overly complex and broader in scope than the notification;
  • the duration of some investigations and the length of time matters took to be finalised was problematic;
  • the limited information provided to the medical practitioner about the details of a notification, and the consequent disadvantage in responding to allegations, was concerning; and
  • procedures did not afford due process – short timeframes to provide additional information and responses, and disparities in sharing information between the notifier and the practitioner under review.

There is no doubt that lengthy investigations are detrimental to the wellbeing of practitioners and colour consumer views about the effectiveness of the process.

Not only this, but fragmented, unnecessary and drawn out processes increase the costs of the scheme.

Rather than wait for the outcomes of the independent review, the AMA offered to provide senior, experienced clinicians to work with the Board and AHPRA to analyse the notification and investigation processes to streamline them to improve the practitioner experience.

We felt this was important given the volume and complexity of medical notifications.

The Board and AHPRA welcomed the idea to strengthen work underway to improve the timeliness and process for managing notifications.

At a workshop held on 5 March, Dr Flynn, Mr Fletcher and senior AHPRA staff met with AMA representatives including myself, Associate Professor Susan Neuhaus (general surgeon and surgical oncologist), Dr Roderick McRae (anaesthetist),
and Dr Antonio Di Dio (general practitioner).  Dr Jonathan Burdon, a respiratory physician, was unable to attend but provided input.

There was common commitment to constructive change and a spirit of goodwill.

The workshop kicked off by identifying what a good system would look like from the practitioner perspective. This included:

  • timely and sensible vetting of notifications and complaints;
  • arrangements for dealing with vexatious complaints quickly, and an alternative mechanism for assisting the complainant to resolve their dispute where there is otherwise no risk to the public;
  • early and personal contact with the practitioner to advise that a notification had been received, acknowledging the impact this can have on practitioners, and explaining how the process will work;
  • recognition by colleagues and employers that notifications are not evidence of sub‑standard practice but are a ‘fact of life’ of medical practice, with investigations being carried out in the interest of public safety;
  • a process that assists the practitioner to gain insight, and supports them to remedy their practice if it is lacking;
  • a process that quickly and fairly addresses unsafe and poor practice, fairly and appropriately;
  • that practitioners be afforded confidentiality during the investigation and decision making; and
  • that there be clear and accessible information about the notifications process to inform practitioners about what to expect.

At the workshop, de-identified case examples were used to identify where processes fail practitioners and to explore improvements.

Summarised below are actions that can be taken to improve the practitioner experience and the operation of the scheme.

Regulatory principles
The regulatory principles that the Board and AHPRA staff use to guide their investigations and decision making will be included in the guide for practitioners and be attached to the initial letter the practitioner receives about a notification. The principles are available on the AHPRA website at http://www.ahpra.gov.au/About-AHPRA/Regulatory-principles.aspx.

Initial assessment response
The letter that invites the practitioner to provide an initial response to the notification will include information about when they will be advised that there will be no further action or an investigation will take place, or any other action that is available to Board. The letter will also provide contact details for a person that the practitioner can follow up with.
The letter will provide the practitioner with reassurance that the process is not intended to punish practitioners, that the notifications process is part of the arrangements for protecting the public, and that due process will be followed.

Reflective lessons
In cases where investigations result in no further action, the Board will look at the factors that were known when the notification was received, and consider how these might inform the notifications vetting process.
The Board will also consider what other methods it can use to assist the practitioner to understand the issue that contributed to the notification being made, and steps that he or she could take to improve the quality of practice.

Investigations beyond 12 months
The workshop identified that there can be several reasons why investigations may not be completed within 12 months, such as waiting for the outcomes of simultaneous investigations, coronial inquiries, court cases etc. In these situations, the practitioner will be provided with more frequent information about how their matter is progressing, in order to help them understand the reasons for the delays. General information for the public will be published about the most common reasons for lengthy delays in resolving notifications.

Transparency about decisions where a Board member is professionally associated with the practitioner being reviewed.
The Medical Board and AHPRA have clear processes in place to manage potential conflicts of interest. AHPRA and the Board will explain to the practitioner how these issues are dealt with by the Board when concerns about this arise.

Expert reports
A policy will be developed to generally provide the practitioner with export reports obtained about them, except when there are specific risks associated with doing so.  

Assessment costs
The Medical Board will clarify that travel costs of the practitioner to attend assessments required by the Board are paid by the Board.

Reworking letters to practitioners
The AMA and AHPRA will continue to work together to improve the letters that are sent to practitioners.

Feedback from practitioners
AHPRA will explore a cost effective mechanism for systematically obtaining feedback from practitioners about how they feel they were treated during an investigation.  

Information about options for the public.  
AHPRA will develop information for the public that sets out the options that people have if they have a grievance, and how they can pursue them.  

Update the Guide to Notifications
The AMA and AHPRA will work on updates to the A Guide for Practitioners: Notifications in the National Scheme to provide practitioners with more information about the investigation and decision-making processes.
The AMA believes these changes to improve the practitioner experience will, in turn, enhance the process for those making notifications.
I would like to reassure all AMA members and the broader profession that, while the scheme has had its teething problems, this is to be expected when eight schemes covering 10 different practitioner groups are brought together. The scheme is now being consolidated and improved.
The AMA wants the profession and the general public to have confidence in the scheme.  To achieve that, the scheme must be fair, timely, transparent and effective.
I am satisfied that, even before last month’s workshop, the Board and AHPRA were making improvements to the scheme. The workshop has meant that those changes are better informed. 
I would like to thank Dr Flynn and Mr Fletcher for their efforts to work with the AMA. The fact that both of them attended the workshop for the full day, along with their senior staff, is testament to their desire to make the scheme the best it can be.
The AMA will continue to work with the Board and AHPRA over the coming months to improve the practitioner experience.

 

 

 


Published: 02 Apr 2015