Tossing a Snowball at the tip of the iceberg

Too many licensing authorities, not enough accountability or power to enforce standards

Fourteen health professions come into the jurisdiction of the Australian Health Professionals Regulation Agency (AHPRA). Having one national licensing authority for the professions instead of separate authorities in each state and territory makes good sense. For doctors, if AHPRA had stopped at one registration fee, and left the paraphernalia to the states and territories, it would have been a modest body and not enmeshed with a national medical board and a national medical council. This awkward arrangement is demonstrated in the recommendations of a recent parliamentary report.1

Peter Drucker, well known management guru, is quoted as saying “Much of what we call management consists of making it difficult for people to work”.2 The article quoting Drucker talks about a “mass of clutter — from bulging inboxes to endless meetings and long lists of objectives to box-tick”. When there are three national medical bodies with interlocking functions, it is unsurprising they are prey to the dysfunctions of bureaucracy.

These are resonant tones for those who have known simpler times. Then, you signed the register in front of a group of venerable peers who called you by your surname and said “I knew your father”. You were invited for a cup of tea, paid 10 quid a year for medical indemnity and were licensed to practise medicine for life.

Kim Snowball, a well respected former head of the Western Australian Health Service, faces a daunting task as the independent reviewer of the National Registration and Accreditation Scheme. He has authored a wide-ranging consultation paper.3 In it, he says that the Board's “role is to protect the public from risks posed by health professionals”.3 From a medical perspective, anecdotally, the Medical Board of Australia has been criticised as being out of touch with its constituents, too slow to act on complaints, and unable to trace its registered membership when they change location. Urban and rural myths develop about outliers in the profession who are too impaired to ply their profession competently but continue to practise undetected. In a submission to the AHPRA inquiry, a rural practitioner wrote: “It appears that there is no supervision of the adherence to these restrictions and supervision requirements. Indeed AHPRA has acknowledged that it has no way of ensuring their restrictions are being adhered to”.4 This statement encapsulates much of the discontent.

The licensing of professional practice is tied to the maintenance of standards, although licensing indicates only the attainment of minimal requirements. In the 1990s, there was a perceived shortage of doctors in Australia. Community pressure from one-doctor towns wishing to recruit doctors was considerable. It was more than an anecdote that a community that was prepared to dump farm produce in front of the Western Australian parliament in protest against rising costs and falling returns5 went to water when its doctor threatened to leave. The mindset that any doctor will do is not conducive to maintaining high standards.

In answering the call for doctors, importing doctors from overseas was a ready-made solution — cheap and no waiting for them to graduate. The Australian Medical Council examination provided a way to assess overseas graduates. However, in a world of minimal standards, it was not long before corporate practice arrived in rural and outer urban settings where “area of workforce need” can be manipulated and throughput can readily become the only indicator of successful practice. Often, the workforce here consists entirely of overseas graduates. Given the numbers being supervised, frequently by one doctor, one would be forgiven for thinking that the supervisor is emulating Robert Towns6 rather than William Osler.

Traditionally, medical licensing is based on the apprenticeship model, whereas the growth of corporatisation is based on the indentured labourer model. Supervision under the indentured labourer model is a cursory glance over the cane fields of professional practice and, if the doctors are seen to be working and reaching their quotas, then the benchmark has been achieved.

This is the challenge for any registration body — what level of supervision should the licensing authority demand and what ability does it have to police it? In one known case, the supervisor approved by the Medical Board of Australia was 600 kilometres away, and owned the practice in which the supposedly supervised doctor worked.

In rural areas, most small settlements have hospitals. Their boards increasingly demand that the doctors be credentialled and privileged for a given scope of practice before being appointed. In the best cases this process is rigorously undertaken. Such a system can identify deficiencies, both in competence and attitude. Owners of medical practices should not escape similar scrutiny. A formal link between the national expectation and local reality should be considered.

It is important that the link between licensing and credentialling and privileging of medical practitioners is strengthened. No community is well served by corporatised medicine, uninterested in building up skills and the intellectual capital in that community.

There is a task for Snowball. The consultation paper is an excellent start, but it should attend more to supervision of new doctors. Is Snowball reluctant because there are so many layers of regulation without regard to enforceability?

Waiting for complaints is far from the best way to supervise a medical profession where, unwittingly, the regulatory agencies have opened Australia to an indentured labourer model.