November 2013

Issue 7, November 2013

• Chair’s message 
• Annual report published 
• Graduate applications now open 
• Medical practitioner renewal 
• Consultations 
  • Review of registration standards
  • Development and review of guidelines
  • Good Medical Practice: code of conduct to be revised 
  • Guidelines on cosmetic medical and surgical procedures 
  • International criminal history checks 
• Update on practitioner audit 
• News 
  • National Internship Framework update 
  • Advice on inter-jurisdictional technology-based patient consultations 
  • Battery hazards alert 
  • Notice to doctors practising in Victoria: rescheduling of alprazolam 
• National Scheme news 
  • Community Reference Group 
  • Panel and tribunal hearing decisions published 
• Appointments to state and territory boards 
• Changing to an electronic newsletter
• Contacting the Board 

Chair’s message

Earlier this year the Medical Board announced that it was starting a conversation with the medical profession and the community in Australia about what further steps we might want to take to ensure that all registered doctors remain competent and up to date. This issue is also being considered in the UK, USA, Canada, Ireland and New Zealand. Medical regulators in these jurisdictions are well down the track.

The process has different names in different places. We are using the term 'revalidation'.

No one argues with the proposition that all doctors need to be competent within their field of practice. The question is whether existing continuing professional development programs and quality assurance processes are sufficiently robust to ensure that this is the case and if not, how the gaps might be filled.

The Board is developing a discussion paper to explore this question. Any new proposals will be evidence-based and will be piloted and evaluated. We are mindful of the diversity of practice types and settings in Australia and of the need not to add burdensome requirements to the lives of busy professionals. We are also mindful that the safety of the health care that patients in Australia receive is dependent on the competence and professionalism of registered health professionals. The Board is responsible for the integrity of the medical register and will be thinking carefully and listening to the views of the profession and the community about what that implies.

The National Registration and Accreditation Scheme (National Scheme) is now three years old and that means that all of the standards and codes that were developed at the outset of the scheme are up for review. This Update provides details about the consultations which will underpin the reviews to ensure that the standards set by the Board are relevant and contemporary.

Finally I draw your attention to the Annual report 2012/13, which is now available online. Some detail about the medical registration and notifications is included in this Update but the full report gives a much more detailed picture of the work of the Medical Board, of the Australian Health Practitioner Regulation Agency (AHPRA) and of the National Boards of the other professions in the scheme.

Dr Joanna Flynn AM
Chair, Medical Board of Australia

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Annual report published

The Annual report 2012/13 has now been published and is available on the AHPRA website.

The annual report contains a wealth of data about all the professions regulated through the National Scheme, as well as specifically about the medical profession. It provides useful insights into the work of the Board and AHPRA. Here are some highlights from the report.

Registrations

• On 30 June 2013, there were 592,470 health practitioners in the 14 professions registered under the National Law¹. Of those, 95,960 were medical practitioners. 
• The number of registered medical practitioners has increased by around 4% per annum in the three years since the National Scheme began. 
• There is a large variation in the number of registered medical practitioners in each state or territory ranging from 30,333 in New South Wales to 992 in the Northern Territory – see Table 1. 
• 38% of practitioners are aged under 40, while 10% are aged over 65. 1.8% of registered medical practitioners are aged over 80 – see Table 2. 
• On June 30 2013, there were 54,226 medical practitioners with specialist registration. Of those, 47,210 also had general registration while 7016 had only specialist registration. 
• There is a very wide range in the number of medical practitioners registered in the various specialties. For example, 23,343 medical practitioners had specialist registration in general practice (39% of specialist registration ), while 113 have specialist registration in sexual health medicine (0.2% of specialist registration²). 
• There are 121,904 registered students in an approved program of study, across the 14 health professions. Of those, 17,618 (14.5% of total registered students across all professions) are in a program of study approved by the Medical Board (i.e. Australian and New Zealand medical schools).

Table 1 – Number and percentage of medical practitioners registered in each state and territory at 30 June 2013

Table 2 – Number and percentage of medical practitioners in five-year age ranges at 30 June 2013

Notifications

• 54% of notifications across all professions were about medical practitioners, who make up 16% of all practitioners. 
• Across all professions, there were 8,648 notifications received (including NSW) which is a 14% increase in the number of notifications lodged compared with last year. 
• Within medicine, there were 4,709 notifications received (including NSW) of which 3,032 were lodged outside of NSW. This represents an increase of 28% on the previous year. These notifications relate to 4.2% of the registrant base nationally, based on the number of practitioners involved in these notifications (some practitioners have more than one notification). 
• There is variation in the proportion of practitioners with a notification across the states. Queensland is the state with the highest proportion of practitioners involved in notifications (5.3%), followed by Northern Territory at 5.1%, NSW at 4.7%, ACT and Tasmania at 4.4%, Victoria at 3.6%, South Australia at 3.3% and Western Australia has the lowest proportion at 3.1%. 
• There were 2,733 notifications closed during 2012/12. This number is less than the notifications received in the same period. The Board and AHPRA are working on strategies to balance timeliness and thoroughness in notifications management.

Of the 2,733 notifications closed in 2012/13:

• 2,200 were closed after assessment 
• 407 were closed after an investigation 
• 45 were closed after a health assessment 
• 64 cases were closed after a panel hearing, and 
• 17 cases were closed after a tribunal hearing.

Of the 2,733 notifications closed in 2012/13, the outcome was:

• 1,674 – no further action was taken 
• 27 – referred to another body (all or part of the notification) 
• 750 – retained by the health complaints entity (HCE) in the relevant state or territory 
• 180 – caution was issued 
• 8 – reprimand was issued 
• 35 – undertakings accepted 
• 48 – conditions imposed 
• 3 – registrant was fined 
• 1 – registration was suspended 
• 6 – registration was surrendered, and 
• 1 – registration was cancelled.

Mandatory notifications

• Including NSW, there were 299 mandatory notifications about 277 medical practitioners received in 2012/13. This is an increase compared with 2012/13 (221). 
• There were 212 mandatory notifications in all states except NSW. The grounds for these notifications were:
  • 138 – the practitioner was placing the public at risk of harm due to practice that constituted a significant departure from accepted professional standards 
  • 36 – the practitioner had an impairment that was placing the public at risk 
  • 18 – the practitioner had practised under the influence of alcohol or drugs 
  • 19 – sexual misconduct in connection with practice, and 
  • 1 – not specified.

These data provide only a glimpse of the full annual report, which also contains much information about the work of the Board.

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Graduate applications now open

AHPRA is now calling for online applications from final-year students seeking provisional registration as a medical practitioner. The online graduate application service aims to smooth the path from study to work for students of approved programs of study by allowing them to apply for provisional registration before they graduate.

AHPRA will email directly final year students on the Student Register, urging them to apply early and online. Students can also apply by completing a paper application form.

All applications, online or in hard copy, require students to post some supporting documents to AHPRA to complete their application. Applicants are urged to apply now so they can be granted provisional registration in time to start their internships at an approved hospital.

Students are encouraged to read the information on AHPRA’s website under Graduate applications.

Helping interns make the transition from provisional to general registration

AHPRA is also encouraging all interns with provisional registration who are approaching the end of their internship to apply for general registration early and online.

Online renewals have been streamlined and made easier to complete. Applicants who have provided certain information under the National Scheme do not need to provide duplicate information. We are also working with hospitals that employ interns, encouraging them to provide certificates of completion of the intern year directly to AHPRA and reduce the administrative burden for applicants.

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Medical practitioner renewal

The Board was very pleased with the 2013 annual registration renewal process. By 30 September, 96% of practitioners who were due to renew had done so and one per cent had opted out of registration. Two per cent more practitioners renewed on time than last year, and six per cent more renewed online.

We have learned in the last three years of the National Scheme that between two and four per cent of practitioners each year don’t renew their registration.

Update: limited registration (public interest-occasional practice)

More than 70% of older, retired doctors with limited registration (public interest-occasional practice) made an active choice about their future registration status.

There were around 600 medical practitioners with limited registration (public interest-occasional practice) whose registration expired on 30 September 2013 and who were not eligible to renew this category of registration. This is because they had previously been granted three renewals under the National Law. The National Law is clear that this type of registration can only be renewed up to three times. These practitioners were able to choose to apply for general registration (and meet the Board’s registration requirements), apply for non-practising registration or opt out of registration.

More than 50% have decided to apply for general registration, 20% have applied for non-practising registration and a further 20% have decided not to register. Only 10% have not responded.

There remain around 400 practitioners with limited registration (public interest-occasional practice) whose registration is due to expire on 30 September 2014 and who will have to make a decision about their future registration status in 2014.

Background information about this category of registration is published on the Medical Board website.

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Consultations

The Board developed registration standards, codes and guidelines for the start of the National Scheme on 1 July 2010. These standards, codes and guidelines were scheduled for review after three years.

Review of registration standards

The Board has begun the review of the registration standards that took effect on 1 July 2010.

The following registration standards are mandatory under the National Law:

1. the requirements for professional indemnity insurance 
2. matters to be considered in deciding whether an individual’s criminal history is relevant to the practice of medicine 
3. requirements for continuing professional development 
4. requirements about the English language skills necessary for an applicant for registration to be suitable for registration, and 
5. requirements in relation to the nature, extent, period and recency of any previous practice by applicants for registration.

The first 10 National Boards to enter the National Scheme agreed that the criminal history and English language skills registration standards would be largely common across all professions. These 10 National Boards, including the Medical Board, will be consulting on these standards shortly.

The Board will also be consulting on the registration standards for professional indemnity insurance, continuing professional development and recency of practice. The registration standards are being reformatted and will be written in more straightforward language. In instances where the Board received feedback that elements of the standards have not worked as intended, the Board is making changes.

AHPRA and the Boards that are reviewing their standards have commissioned a number of reviews of the literature on the issues relevant to the registration standards, particularly in relation to English language skills, recency of practice and continuing professional development. The Board will take these into account, along with three years’ experience with the current standards, in its review.

Registration standards for limited registration 

The Board is also reviewing a set of registration standards that are relevant to international medical graduates (IMGs). IMGs who are not qualified for general registration or specialist registration can apply for limited registration. The following registration standards for limited registration support the registration processes for IMGs:

• limited registration for postgraduate training or supervised practice 
• limited registration for area of need 
• limited registration for teaching or research, and 
• limited registration in public interest.

When the Board consults on the revised registration standards for limited registration, it will also consult on the draft guidelines on the ‘Specialist pathway – short-term training’. This pathway allows internationally qualified specialists, or specialist trainees who have nearly completed specialist training in another country, to apply for limited registration for postgraduate training or supervised practice so they can undertake short-term training in Australia without having to sit the Australian Medical Council (AMC) examination. The guidelines and registration standard for limited registration for postgraduate training or supervised practice are related.

The consultation documents will be publicly available from the Board’s website under the News tab. Stakeholders are encouraged to provide feedback to the Board to help inform the next version of the standards.

Development and review of guidelines

During 2013, the Board consulted on the following guidelines, which are common to all National Boards:

• revisions to the Guidelines for advertising 
• a Social media policy, and 
• revisions to the Guidelines for mandatory notifications.

These guidelines are being finalised, taking into consideration stakeholder feedback and will be published on the Board’s website under Codes, guidelines and policies.

Good Medical Practice: code of conduct to be revised

The Board's Good Medical Practice: A Code of Conduct for Doctors in Australia has been in place since 1 July 2010 and is now due for review.

The first edition of Good Medical Practice was developed by a working party of the AMC and preceded the National Registration and Accreditation Scheme. The Board adopted Good Medical Practice in 2010 with minor revisions.

The Board has reviewed Good Medical Practice recently and proposed minor changes, primarily to ensure it reflects the current regulatory framework. We have added a reference to any new guidelines developed by the Board since the release of the code in July 2010 and added references to social media and technology-based patient consultations.

The Board consulted widely on the code before the end of the consultation period on 27 September 2013. The Board received valuable comments from a range of stakeholders and is now considering this feedback. The revised Good Medical Practice will be published on the Board’s website under Codes, guidelines and policies.

Guidelines on cosmetic medical and surgical procedures

In 2012, the Board consulted on supplementary guidelines to Good Medical Practice: A Code of Conduct for Doctors in Australia on cosmetic medical and surgical procedures. After receiving feedback from that consultation, the Board decided not to proceed with the supplementary guidelines but rather, to develop specific guidance in relation to the professional standards expected when medical practitioners perform cosmetic medical and surgical procedures. The Board has developed Guidelines on cosmetic medical and surgical procedures and will consult with stakeholders in the coming months. The consultation will provide an opportunity for practitioners and the community to comment.

Information about the consultation will be published progressively on the Board’s website.

International criminal history checks

All National Boards have undertaken further public consultation on a proposal to refine international criminal history checks used by AHPRA to assess applications for registration for the 14 health professions regulated under the National Law.

In the current draft, the National Boards aim to balance public protection with the need for responsive and timely application and assessment processes for health practitioners seeking registration in Australia. After the consultation has finished, the Boards will decide whether to implement the proposed option and will publish information about their decision in due course.

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Update on practitioner audit

All registered practitioners are required to comply with a range of registration standards that have been developed by the Board that registers them. The registration standards are published on each Board’s website under Registration standards.

AHPRA and the National Boards are developing a nationally consistent approach to auditing health practitioners’ compliance with mandatory registration standards. Pilot audits have been conducted for the chiropractic, optometry and pharmacy professions. The pilot audits were designed to determine the frequency, size and type of audits required and establish our audit methodology.

The results of phase one and phase two of the audit pilots are available on the AHPRA website under Registration. The phase two audit pilot was conducted in line with the recommendation of the phase one audit pilot report and involved auditing a fixed sample size from three professions.

A third phase started in May 2013 for the nursing and midwifery professions. The results from all phases of the pilot will be used to develop an overall auditing framework and audit program, which will be rolled out to all regulated health professions across Australia.

Each time a practitioner applies to renew their registration, they must make a declaration that they have met the registration standards for their profession. Practitioner audits are an important part of the way that National Boards and AHPRA can better protect the public by regularly checking the declarations made by a random sample of practitioners. Audits help to make sure that practitioners are meeting the standards they are required to meet and enhance the trust of the community in the profession by providing important assurances that practitioners are meeting their professional and legal obligations.

The Board and AHPRA will start auditing medical practitioners from February 2014. We will work with stakeholders to ensure smooth implementation of the audit process and will keep you informed of progress.

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News

National Internship Framework update

The Board has an approved registration standard for granting general registration to Australian and New Zealand medical graduates on completing their internship. This will be implemented for interns starting their intern year in 2014. The standard can be found under Registration standards on the Board’s website.

On successful completion of an approved intern year, Australian and New Zealand medical graduates can apply for general registration with the Board.

The Board has asked the AMC to do a range of work related to the intern year as part of a new national framework. This includes:

• global outcome statements for the intern year 
• national standards for intern training, and 
• guidelines for rotations during the intern year.

The AMC, on behalf of the Board, will assess the performance of organisations that accredit intern training against agreed standards. These reviews will focus on intern training accreditation and will not address other functions performed by these organisations. To date, the AMC has conducted a pilot with two postgraduate medical councils to test its proposed review framework.

The Board and the AMC publish regular newsletters on the progress of this project. For more information see the third edition of the National Internship Framework newsletter. This can be downloaded from the Board’s website under News, or on the AMC’s website.

Advice on inter-jurisdictional technology-based consultations

Telehealth and technology-based consultations are increasingly being used to improve access to medical services, particularly in rural and remote areas.

In 2012, the Board issued Guidelines for technology-based patient consultations to inform registered medical practitioners and the community about the Board’s expectations of medical practitioners who consult a patient outside the traditional face-to-face setting, such as by video-conferencing, internet and telephone.

The Board is aware that this technology is now being used across international jurisdictions. In this context, jurisdiction refers to countries or regions outside Australia (i.e. consultations conducted when the patient or the practitioner is outside Australia).

The Board has developed additional information to assist medical practitioners in relation to their registration and liability obligations for technology-based patient consultations conducted when either the patient or the practitioner is outside Australia.

The Board expects that medical practitioners who are providing technology-based consultations to patients in Australia will be registered with the Medical Board of Australia regardless of where the practitioner is located.

Those who conduct technology-based consultations with a patient who is outside Australia must establish whether they are required to be registered by the medical regulator in that jurisdiction (for example, the General Medical Council for a patient in the United Kingdom).

The Board also expects that practitioners will:

• consider the appropriateness of a technology-based consultation for each patient’s circumstances 
• comply with the requirements of the National Law and the Board’s registration standards, codes and guidelines including the Professional indemnity insurance registration standard, which requires that a medical practitioner is covered for all aspects of their medical practice, and 
• ensure that their patients are informed about billing arrangements for consultations and whether the patient will be able to access Medicare or private health insurance rebates.

The guidelines and the information sheet are available on the Board’s website under Codes, guidelines and policies.

Battery hazards alert

From time to time the Medical Board of Australia is asked to publicise important public health messages to medical practitioners.

A recent case in Queensland in which a four-year-old girl died after ingesting a button battery has prompted the Australian Competition and Consumer Commission (ACCC) to issue an urgent alert about the dangers of lithium button batteries.

When swallowed, batteries can become lodged in the oesophagus and the residual charge can cause electrolysis. This burns through tissue causing severe, irreversible damage.

Doctors may not be aware of the risks or the urgent need for intervention in these cases. Recognising battery ingestion can be difficult if the ingestion is not witnessed, as the child may present with non-specific symptoms such as poor feeding, irritability, fever, vomiting, drooling or cough.

Doctors are urged to be vigilant to the risks of button battery ingestion, especially in young children, and refer children for urgent x-ray if battery ingestion is suspected.

Further information is available from the ACCC or advice can be obtained by ringing the Poisons Information Centre in Australia on 13 11 26.

Notice to doctors practising in Victoria: rescheduling of alprazolam

Alprazolam has been rescheduled to Schedule 8 in the Standard for Uniform Scheduling of Medicines and Poisons in Victoria from 1 February 2014.

The Department of Health in Victoria has asked the Board to inform medical practitioners who practise in Victoria about a document titled Alprazolam to become Schedule 8: information for prescribers – from 1 February 2014. The document is available at www.health.vic.gov.au/dpcs/reqhealth.htm.

The document provides a summary of the reasons for rescheduling alprazolam and includes the Department’s policy for issuing permits to prescribe alprazolam. It also contains links to clinical guidelines and patient guides available for the treatment of anxiety disorders.

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National Scheme news

Community Reference Group

The newly established Community Reference Group had its first meeting in June 2013. This is the first time a national group of this kind, with a focus on health practitioner regulation, has been established in Australia.

The group has a number of roles, including providing feedback, information and advice on strategies for building better knowledge in the community about health practitioner regulation, but also advising National Boards and AHPRA on how to better understand, and most importantly, meet, community needs.

Members are listed on the Community Reference Group Members page and communiqués from the group’s meetings are published on the Communiqués page after each of its meetings.

Panel and tribunal hearing decisions published

We publish a list of panel hearings conducted since July 2010, including summaries of the case when there is educational and clinical value. Practitioners' names are not published, consistent with the requirements of the National Law. These can be found on the AHPRA website under Legislation and publications>panel decisions.

Published hearing decisions from adjudication bodies (other than panels) relating to complaints and notifications made about health practitioners or students are available in the Australian health practitioner law library on the Austlii website.

Some summaries of tribunal decisions are also provided, to help share information and guide practitioners. These can be found under Legislation and publications>Court and tribunal decisions on the AHPRA website.

AHPRA is also publishing a series of legal practice notes to support the consistent understanding and application of the National Law by National Boards and AHPRA staff. These are available on the AHPRA website, also under the Legislation and publications tab.

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Appointments to state and territory boards

There will be a number of vacancies for positions on state and territory boards in 2014. We expect that these positions will be advertised in November 2013.

Anyone who is interested in receiving further information about these positions can express an interest by emailing their details to boardappoint@ahpra.gov.au. Your contact details will be kept on file and we will send you additional information when the vacancies are advertised.

Background

The Medical Board of Australia (the National Board) has established boards in every state and territory. These boards make registration and notification decisions about individual practitioners, based on national policies and standards set by the National Board. The National Board has delegated the necessary powers to the state and territory boards to enable them to carry out their work.

There are 12 members appointed to the South Australian, Tasmanian, Victorian and Western Australian boards, nine members appointed to the Australian Capital Territory and Northern Territory boards and six members appointed to the New South Wales board. There is a mix of practitioner and community members on each board.

Our role in the appointment of state and territory board members

AHPRA, which works in partnership with the National Board, can advertise board vacancies and provide support for the appointment process.

The Health Minister in each jurisdiction appoints the board.

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Changing to an electronic newsletter

The Board will be phasing out this hard copy edition of its newsletter, Update and moving towards publishing and distributing an e-newsletter. While future newsletters will be available online through the Board’s website, we encourage all registered practitioners who have not already done so to provide AHPRA with their current email address. This will make it possible for the Board to send information about regulation directly to practitioners by email, and for AHPRA to continue to send registration and renewal reminders.

One of the Board’s most important jobs is to set standards, policies and guidelines to protect the public, that all registered practitioners must meet. The Board expects practitioners to be familiar with – and to meet – these. The Board informs the profession about its expectations in newsletters and by publishing information on its website. Practitioners are responsible for being aware of the Board’s expectations.

To update your email address for future newsletter alerts, regulation information, and registration and renewal reminders, go to the AHPRA website and use the secure health practitioner login (Your account) at the top right corner of the home page.

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Contacting the Board

• The Medical Board of Australia and AHPRA can be contacted by phone on 1300 419 495. 
• For more information, see the Medical Board of Australia website and the AHPRA website. 
• Lodge an enquiry form through the website under Contact us at the bottom of every web page.
• Mail correspondence can be addressed to: Dr Joanna Flynn, Chair, Medical Board of Australia, GPO Box 9958, Melbourne, VIC 3001.

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