Lessons Learned, Changes Made - a new era in Australia Dr Joanna Flynn Chair Medical Board of Australia

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 Australia

Brief history of Australia First Australians arrived > 50,000 years ago Terra Australis – imagined by Aristotle, seen by Portuguese, Spanish, French, Dutch 16th - 18th 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

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 37

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, Victoria

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

Is medical regulation failing? - the sorry saga of Dr Patel

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 history

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 hearing

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 jail

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”

Commission of Inquiry findings 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 position

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 Professions

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 restrictions

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 concerns Mandatory reporting

A new era in health professions regulation in Australia

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

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 2010

Eight States and Territories > 85 health profession boards Before July ‘10 Since July ‘10 Eight States and Territories > 85 health profession boards 66 Acts of Parliament One national scheme (+WA) 10 health profession boards (+WA) Nationally consistent legislation 22

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 months

Guiding principles… national scheme to operate in transparent, accountable, efficient, effective and fair way registration 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 quality

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 practitioners Facilitate access to services in the public interest Enable continuous development of a flexible, responsive and sustainable Australian health workforce and enable innovation in education and service delivery

State/ Territory/ Regional Ministerial Council Advisory Council National Boards Agency Management Committee National Committees State/ Territory/ Regional Boards National Office State and Territory Offices Support Accreditation Authorities Contract Advice Structure…

Health Professions… July 2010 July 2012 chiropractors dental care (including dentists, dental hygienists, dental prosthetists & dental therapists), medical practitioners nurses and midwives optometrists osteopaths pharmacists physiotherapists podiatrists psychologists July 2012 Aboriginal and Torres Strait Islander health practitioners Chinese medicine practitioners medical radiation practitioners occupational therapists

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 prosecutor

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 AHPRA

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 property

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 registration Independent accreditation functions Australian Medical Council appointed for medicine

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 subsidies No cross profession subsidisation

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 standards

Notifications… Act also allows for voluntary notifications Protection from liability for persons making notifications or providing information in good faith

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 provided

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 Agreements Agreements with Accreditation Agencies Mandatory reporting guidelines issued Advertising guidelines issued

Registration in new scheme Registration type/subtype Number General only 24,236 General & Specialist 38,026 Specialist only 5,594 Limited Public interest – occasional practice 1,410 Teaching/research 185 Area of need 2,069 Public interest 494 Postgraduate training 3,442 Non-practising 2,475 Provisional 2,180 Registration in new scheme

Noticeable Differences Registration fees Requirements for CPD, Recency, PII Specialist registration Identity – AHPRA, MBA Communication and relationships Policies and procedures Outcomes?

Where to from here?

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 1995

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 2007

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 regulation

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 Funding

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 profession

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 performance

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