Speech to MIIAA 3rd Medical Indemnity Forum - AMA President, Dr Andrew Pesce, Sydney, 28 August 2009

Costs and registration fees

Our first major concern with the proposed scheme is the costs implications.

The system will be self-funding.

The proposed scheme has a multi-layered structure.  There is a new corporate agency, new shopfronts and additional advisory committee.  We think it is inevitable that the scheme will cost more than the current arrangements.

Registration fees will go up.

I know that the other health professions are concerned about this,  too.

We have continually said that if registration fees under the new scheme exceed existing registration fees, governments must cover the additional costs of the scheme.

I welcome the Health Ministers’ decision to do away with the Public Interest Assessor.  This would have added administrative layers to the complaints handling processes and costs to the scheme.

Registration arrangements

In terms of the registration arrangements themselves, the challenge for Dr Morauta and her colleagues has been to redesign a national system that tries to take the best from each State and Territory and from each professional arrangement. 

Undoubtedly Louise has heard many views - some put quite strongly - about what 'best' means. 

New systems have had to be designed for categorisation of registration, protection of titles, complaints handling arrangements and disciplinary pathways.

Some of these elements have been strongly resisted by States and Territories – with each one saying their practice is 'best' practice.

In contrast, the AMA made the case that some issues, such as existing complaint handling and disciplinary arrangements, have evolved over time in response to local issues and should be able to continue to do so.

And so we have seen some of these processes quarantined from the standard national arrangements.

For example, each jurisdiction will be able to choose how to handle complaints, prosecutions and investigations – under State or Territory law - or under the national law.

The many discussion papers put out by Louise and her team provided opportunities for the AMA to offer its views and solutions to some of the technical registration issues.  We had concerns about proposals for new elements of the registration process.

For example, we had things to say on when it was appropriate for an applicant to undergo a health assessment in order for a Board to assess a person's capacity to practise.

And we had concerns about the extent to which criminal histories were used by boards.  This has now been wound back to a more acceptable arrangement.

The AMA advocated for the Medical Board to be chaired by a medical practitioner and for at least two-thirds of the Board members to be medical practitioners.

And we want the National Medical Board and State and Territory Boards to have the support of the medical profession through a nomination process for the medical representatives.

We had sought, and I am pleased that the Health Ministers have now agreed, that each jurisdiction will have a medical practitioner representative on the national medical board.

From the start, we supported protecting all patients of all health professionals through professional indemnity insurance for the health care that they provide.

And we asked that you, the professional indemnity insurers, be consulted to reach a practical solution around proof of indemnity coverage at the time of registration.

We also encouraged government to take advice from the medical indemnity insurers about the complex issue of mandatory reporting requirements. 

I am not confident from yesterday’s announcement that Health Ministers have made the necessary changes on mandatory reporting recommended by the indemnity insurers.

I understand that the next speaker will talk about these arrangements in more detail.

I have some empathy for Louise having to sort through all of the interests.

The Federal AMA also represented the State and Territory AMAs, who have their own views on what should happen in their jurisdictions on certain issues. 

For example, the Health Ministers have now recognised the need for the new arrangements to accommodate the various existing arrangements for medical practitioners who practise occasionally.

The Federal AMA recognised that for some of these issues it was appropriate for our State and Territory colleagues to make their own submissions about these local issues. 

Accreditation

In respect of accreditation – the second part of the N-RAS equation – the medical profession already has an autonomous process for the development and setting of accreditation standards for medical education and training, and for accrediting medical courses.

This process enjoys the highest level of professional expertise and input, and it is free from political and bureaucratic interference.

This model is strongly supported by the AMA and the medical profession.

And, as I said earlier, no-one has identified any problems with this process.

Let's go back to the Productivity Commission study for a moment. 

Underpinning the whole study, and certainly apparent in the various government submissions to the study, was a covert workforce agenda. 

A 'one size fits all' accreditation arrangement would facilitate 'workforce adaptability' - a term that really means expansion of scopes of practice.

It was pleasing to see that throughout the consultation process the other health professions were as concerned as the medical profession about this very issue. 

I believe that the States and Territories would still like to use this vehicle to manipulate workforce change, and that there are probably some in the Commonwealth bureaucracy who still have this agenda, too.

The AMA has maintained that there is no case to be made for dismantling the current accreditation arrangements for medical education and training.

There is no case to revise them, to change the accountability framework, or to involve governments or politicians in the process.

Now, I recognise that some of the other professions, such as nursing, don’t have a national process or framework for accreditation of their education and training.

I am also aware that the medical model, with the Australian Medical Council at the helm, is held up as internationally recognised best practice accreditation.

This is something that the other professions need to aspire to.

Notwithstanding all of that, the COAG model lumps accreditation for all health professions together and, certainly for the medical profession, allows unacceptable government involvement in setting the standards for accrediting education and training courses.

I acknowledge the practical link between registration and accreditation.

Medical Boards have always used the AMC accreditation arrangements to determine who should be registered to practise as a doctor.

There is little point in a person going through a training course to become a doctor and then find that he or she can’t get registration because the course is not recognised by the board.

However, the AMA has always argued that there is no need to require the two processes to be done by one body, under the auspices of one structure, or to be regulated and administered through the same process.

To a certain extent, we have won that argument and I would point out that the considerable efforts and actions of the AMA have delivered this outcome.

Why do I say this?

Well, the draft legislation has separated out these processes.

The accrediting body will independently accredits courses.

In a separate process, the Medical Board will approve courses for registration purposes.

This would see a clear separation of the registration and accreditation functions, as occurs now.

And yesterday we learned that the national boards will be responsible for appointing the external accrediting bodies, a pleasing result for the medical profession.

So where are our concerns now?

The AMA acknowledges, and is pleased, that the Ministerial Council has forfeited the power to approve accreditation standards originally proposed in the IGA.

We also note that some Health Ministers will be forfeiting existing jurisdictional powers. 

However, the Ministers have retained a reserve power in respect of accreditation standards, which we believe carries a risk that the Ministers will seek to influence accreditation standards, and therefore the training of our future doctors.

Clause 10 of the Bill says the Ministerial Council may give a National Board a direction on a particular accreditation standard for a health profession if, in the Council’s opinion, the accreditation standard will have a substantive and negative impact on the recruitment or supply of health practitioners to the workforce.

Health Ministers have announced yesterday that clause 10 will now include a requirement that they must first consider the potential impact on quality and safety before anything else.

We don’t believe the proposed additional words for this clause are robust enough to protect the public interest in terms of the accreditation standards for medical education and training.

There is no guarantee that Health Ministers will act on this consideration, and as I said earlier, no guarantee they will have to put safety and quality – and other public interest considerations – before workforce supply considerations.

Given the serious risks this could pose, I don’t know why Ministers couldn’t have agreed to the AMA’s suggestion to require Ministers to undertake a full public interest test before exercising their power to issue a direction to the medical board in relation to accreditation standards.

The Senate Community Affairs Committee agreed with us on this issue.

In its report on its inquiry into the scheme, the Committee recommended that the Ministerial Council fully consider and evaluate the potential usefulness and feasibility of the proposed amendments to clause 10, as proposed by the AMA. 

This is another issue that the other professions should be concerned about. 

This is a threshold issue for the medical profession. 

I don’t want to downplay the importance of getting the operational mechanics right around the details of registration and the administration arrangement for registration that I spoke of earlier.

But this issue of Ministerial involvement in setting accreditation standards for medical education and training remains a critical concern.

The AMA will be calling on each state and territory parliament to amend the Bill when it comes before them to make it more robust in its protection of the public’s interest.

The Health Ministers must be required to apply a public interest test before issuing policy directions to the medical board on accreditation standards.

We remain very concerned about this issue.

If the final scheme allows Ministers to issue directions on accreditation standards that we believe will compromise the public interest, we remain open to looking at alternative, more independent registration and accreditation arrangements for doctors, not under this N-RAS scheme.

We must ensure that the public interest, in terms of the future training of doctors in Australia is not compromised.

This new scheme needs to deliver its first objective as set out in the Bill.

That is to protect the public by ensuring that only health practitioners who are suitably trained and qualified to practise in a competent and ethical manner are registered.

The National Registration and Accreditation Scheme must keep our health system safe.

Thank you.

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John Flannery
02 6270 5477 / 0419 494 761
Peter Jean
02 6270 5464 / 0427 209 753