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

2. 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

3. 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 ;160,000 convicts
Free settlers from 1790’s
Gold rush, farming, mining
1901 Federation of six states, population 4M

4. 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

6. 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

7. 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

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

11. 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

12. 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

13. 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

14. 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”

15. 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

16. 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

17. 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

18. 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

19. A new era in health professions regulation in Australia

20. 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

21. 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

22. 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

23. Legislation…
Act A – The Health Practitioner Regulation (Administrative Arrangements) National Law Act 2008 (Queensland)
Act B – Health Practitioner Regulation National Law Act 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

24. 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

25. 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

26. 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…

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

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

35. 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

36. 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

37. 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

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

39. Where to from here?

40. 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

41. 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

42. 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

43. 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

44. 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

46. 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

47. 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