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National registration and accreditation scheme for doctors and other health care workers

CHAIR —Good afternoon. I welcome representatives from Medical Deans Australia and New Zealand. Are you both deans?

Prof. Carmichael —Yes, I am Dean of the Faculty of Health Science and Head of the School of Medicine at the University of Tasmania.

Prof. Smith —I am Dean of the Faculty of Medicine of the University of New South Wales.

CHAIR —I always find out, just in case—and we have at least one Tasmanian in the group! You have received information on parliamentary privilege and the protection of witnesses and evidence. We have your submission, thank you very much. I invite both of you, or either of you, to make an opening statement and then we will go to questions. You have seen the way we operate; it is just a matter of working through the issues as they come up. Have you tossed a coin to see who goes first?

Prof. Carmichael —Thank you very much. I think I am going to start—we will start from the bottom of the country, if you like!

Senator BILYK —It is a very important part.

Prof. Carmichael —Yes. Thank you very much for allowing us to come and speak with you and also for receiving our submission. We, as you know, represent the medical schools of both Australia and New Zealand. We have all of the medical schools as members. Our focus, in that capacity, is to promote medical education, training and research. Our interest in registration and accreditation comes from that perspective and has, as its basis, the quality and safety of health care in the long term, particularly medical care, and ensuring that the Australian medical education system retains its very high international standing—so it is not just regarded well nationally; it is certainly regarded as being in the top rank internationally as well.

We are supportive of the process of national registration and accreditation for those reasons and, particularly, of the principles that have been set out in the intergovernmental agreement. We have some specific issues with regard to registration, particularly around the area of registration of medical students. That is something that we would wish to see nationally. A number of states already require it. Other states, I think, would pick it up but, to some extent, are waiting on a national process. That has stalled things for a couple of years in a number of jurisdictions—Tasmania being one of them, in fact.

The other major area we are interested in, and concerned about, is that of accreditation. This is really fundamental to the standing of medical education in Australia. It has been particularly important in recent times, as we have almost doubled the number of medical schools over the last decade—certainly doubled the number of medical students. To have a national body of high standing that promotes and ensures the standards and quality of medical education is quite important.

The Australian Medical Council, through their Medical School Accreditation Committee and the assessment teams that provide the input into that body with regard to each school, have been extremely important in ensuring that all the existing schools and the new schools meet an appropriate standard. They ensure that the graduates that all the medical schools produce are equipped to enter practice as interns when they graduate and also have the ability to train in any future branch of the profession subsequently. We believe that role has been extremely important. The national focus has been particularly important. It is regarded as international best practice. It has in fact been used as a model for the World Federation for Medical Education standards—both the minimum standards, which they use in developing countries, and the best practice standards, which were very much modelled on some of the AMC standards. That is an area that we are particularly keen to see continue, not only through the transition processes it proposes but also into the future process as, in our view, that ought to be the profession specific body for medicine. I might pause at that point and see if Peter wants to add anything.

Prof. Smith —Could I just pick up the student education registration issue, which I think is very important. I am an Australian but I was Dean of Medicine at the University of Auckland for four years, where they did not have student registration. In New South Wales we do. I think it is critically important. There are two standards we apply to medical students. There is an academic standard—you have to pass your exams to get your MBBS—but then there is a professional standard. It is not just knowledge and skills, but it is attitudes. I think we need to impress on our students very early on that they are entering a profession where things are taken quite seriously. There are some behaviours and some issues that are not acceptable in a medical faculty or in a medical student body that might be accepted in the faculty of fine arts or somewhere. I can give you examples if you want them. You probably do not want to hear them! But I think that is quite important. There is an issue of impressing on the students that they are entering a serious profession.

The other issue is from the Medical Board’s point of view. There are some students who are impaired in some way, and I think it is important that the board knows about this sooner rather than later because these are often the students who will appear before the board later on in their careers. At the moment, some jurisdictions have student registrations and some do not. The move to national registration has very strong support from medical deans, but I think we should have student registration alongside it.

CHAIR —Which states have it and which states do not?

Prof. Carmichael —At the moment I think Victoria, New South Wales and South Australia have registration of medical students. Western Australia does not have a full registration system. It certainly has some sort of register, but it is not under the same process as the other three states, as I understand it.

CHAIR —So it is the two biggest ones.

Prof. Carmichael —As I mentioned earlier, there is certainly a willingness to proceed in a number of other jurisdictions. I will just cite Tasmania. There is agreement by all parties—the Medical Board, the university and the student body—that it ought to proceed. But in fact it has just been held up because people are saying, ‘We’ll wait for the national registration.’ There is no impediment in any sense to the process occurring; it has just been held up because of this process currently.

Senator HUMPHRIES —Professor Smith, on that point you were making about impaired students, could you just explain that a little more? What do you mean by impaired?

Prof. Smith —There can be medical impairment. A student may develop psychological problems, and we assess the severity of them. If it is reactive because they have broken up with their boyfriend or girlfriend or some issue like that, that is one thing, but if it looks like there is an ongoing psychological or mental health impairment we will notify the Medical Board of that. We do that not in a punitive way but simply so that the Medical Board can make its own assessment. The other impairment is impairments of behaviour, which might not result in a student being expelled from a university but might be issues that should come to the attention of the Medical Board.

We actually get into—I do not know whether you do, Allan—issues sometimes with the university administration where we say, ‘We don’t really think this person should be continuing with the program,’ for particular reasons, and we get told, ‘Well, hang on; they’re passing their exams.’ They might be getting deferments and passing them every second year, but we can see quite clearly that this person is never going to function as an intact medical practitioner.

Senator BOYCE —Could you give us some examples of why. Are we talking about people with psychological problems?

Prof. Smith —I could give you an example of a behavioural problem, and I will give you one from New Zealand, where one of our medical students forged some prescriptions. Now, that was a police matter but it was not a matter that would lead to expulsion from the university; it led to suspension. The university ruled that it was not a matter that led to that student not completing an academic qualification, but a medical board would, as I as a dean in fact did, take that as a matter of great seriousness, because we know that people who behave like that as undergraduates will be in trouble later on. So that is a behavioural example, perhaps a fairly extreme one.

Senator HUMPHRIES —Do you think, for the reasons that you have given, that this concept of registration for medical students should apply to other health occupations?

Prof. Carmichael —It is not, in a sense, our prerogative to say what ought to happen, but some of us do sit as deans of faculties of health sciences and hence have other health professions within our faculties. I think the view is that it ought to be a requirement at the point at which students in whatever profession come into clinical contact with patients. So it might be quite different at different stages. We would argue, for medical students, that it ought to be at enrolment, because in every course there is contact with patients right from year 1. But, if you were to look at something like psychology, where clinical contact might only occur in the last two years, then probably registration might be looked at at that stage rather than right at the beginning of the course. And some of the other courses could be varied. So that it is some of the discussion that has occurred in relation to the range of, say, the 10 professions.

Senator HUMPHRIES —Were either of you gentlemen involved in any of the consultation processes that lead to the issuing of the discussion papers or the drafting of the legislation that has been tabled already?

Prof. Carmichael —Certainly, as medical deans we have been involved with each of the discussion papers as they have come out, we have been to the consultations and we have responded to those papers and consultations. To some extent, some of our submission is drawn from some of the prior work, but it has been brought up to date, to the stage we are at at the moment.

Senator HUMPHRIES —I asked the question to understand the dynamic of this process, which seems to have resulted in a fairly significant divide. There is the outcome where responsibility for registration and accreditation should be rolled into the one body, whereas the belief of the people we have been hearing from at least is that they should be separated. Were those points about the separation of accreditation and registration or the preservation of an independent process being made in the course of the consultations you took part in?

Prof. Carmichael —Certainly, they were, yes. I think there is more uniform agreement about the necessity for and perhaps the ease of developing the national registration process. We are a bit confounded by the accreditation issue, which has a number of other factors associated with it, I think. Particularly, when it comes to medicine, I think the role of the AMC is a paramount one which people have looked at, and it is very different from the roles some of the other accreditation bodies for other professions have had. Indeed, in some professions they actually lack a similar accreditation process.

Senator HUMPHRIES —If the objective is a national system so that everybody, no matter where they are in Australia or where they go to in Australia, is treated the same—whereas you do need to bring disparate state components together for a national registration scheme—we have already really got a national accreditation scheme, haven’t we, under the auspices of the AMC?

Prof. Carmichael —Exactly, yes.

Senator HUMPHRIES —Do you believe that the issue of independence of this process is one that is shared by others? We have heard from peak bodies like yourselves and the medical colleges and so on. Is the issue of the independence of that process as important to ordinary practitioners out in the field—ordinary doctors, GPs practising in suburbs around Australia—or is this a more academic consideration for people at this level?

Prof. Carmichael —I do not know if I could comment on how the GPs might view it. I think the issue is really one of assuring the public about the actual standard and the uniformity of that standard across the country. That is a significant issue of accreditation, as far as medical education is concerned at least. I suspect that all graduates of Australian medical schools recognise that they have come through a process that has that standard of quality attached to it, if you like, and they would recognise and agree with that. How much they might want to proactively argue for that, I could not really comment on.

Senator BILYK —I have just a couple of clarification issues. How are things currently accredited? What is the makeup of the board?

Prof. Carmichael —The Australian Medical Council took over accreditation of medical schools from the GMC, the General Medical Council, of the UK in the seventies to eighties. Its new process probably really took effect from the early nineties, following the Doherty inquiry. The Australian Medical Council then set up a body within it to particularly look at medical school accreditation, and it was really designed to look at curricula, resources and the appropriateness of standards of that education for each medical school. The original process was that the then 10 medical schools were considered to go through that accreditation process every 10 years. So the process was started around 1990. And, for all the existing schools, some of them got the full 10 years and some of them got lesser amounts.

But then the medical education system underwent a fairly dramatic change, in that a number of schools decided they would radically change their curricula. Probably the major change was with three of the schools developing graduate medical entry programs, and that necessitated the Australian Medical Council setting up an assessment process at the beginning, to look at those changes and see if they would actually meet the standards of graduates. Then most of the other schools—in fact all of them in one way or another—set about reforming their curricula. So the amount of work undertaken by the AMC in the last decade has been quite extensive. As I have said, 10 new schools were then established that had to start off from scratch. At least all the others had some sort of track record of their program and the ability to place students in hospitals in the community, so people knew what they were dealing with. With all the new schools, that had to be assessed right from the beginning.

What happens with each accreditation is that a specific assessment team is created by the medical school accreditation committee, which receives a very extensive self-assessment from the school itself, addressing the AMC standards for medical education. That is then assessed by the team. There is some discussion between the school and the team about issues they want to clarify from the written—

Senator BILYK —Sorry—who makes up the team?

Prof. Carmichael —The team is a group that is chosen by the medical school accreditation committee. It would have people who represent various areas or who have come from various areas of the profession.

Senator BILYK —Students?

Prof. Carmichael —It has a student representative. It usually has a consumer representative and most recently we have also seen an Indigenous representative as well. So there is a team usually of about half a dozen to eight depending on the accreditation of a particular school at that time. After a couple of iterations of the documents, there is a visit usually of about a week of that team to the school. That team will interview staff members, consumers and students and will visit a number of the sites where the program is undertaken and then it will write its report. That will go back to the Medical Schools Accreditation Committee, which may or may not accept its recommendations as they are written. When it goes through the Medical Schools Accreditation Committee, it is put to the AMC, which again has the ability to further question or seek other information. It is a very rigorous process. It is quite resource intensive, which we have alluded to. But I think, despite that, it is a process that medical schools value and it has certainly been a driver of change over the last 15 years or so.

Senator BILYK —Just to follow on from that, your concerns are therefore that, if it becomes a government role or a ministerial role, it may lose its credibility. Is that right?

Prof. Carmichael —We think it ought to retain that level of both independence and expertise both from the medical school and what might be any professional or political interference, for want of a better word.

Prof. Smith —I would like to comment on that. There are three issues at the national level. One is accreditation, which I think is very well handled at the moment by AMC, as Allan described. That is an independent body. Another is the registration issue. I think it is really important that we get that straight. I have practised within three states and I have to get registered in each state when I do that. You know all the stories. While the AMC oversees curricula and accredits medical schools, you are probably aware that we have great diversity in our medical schools. Ours is a six-year undergraduate program, with a bachelor of science degree in the middle. Another is a five-year undergraduate program, and there are four-year graduate programs. Also, the students we recruit are quite diverse. One of your previous attendees said something about them all being school captains or something. They are not. We recruit 25 per cent from rural origins—

Senator BOYCE —It is just the dermatologists, I think, Professor Smith!

Prof. Smith —They are all school captains—exactly.

CHAIR —Professor, do you have the interview process before—

Prof. Smith —Yes.

CHAIR —Some schools have that and some do not. The University of Queensland has moved away from it, I think. That has been contentious as well—plus academic results, plus a pre-assessment interview with a group of people. Do both of your schools have that?

Prof. Carmichael —No, we do not.

CHAIR —You do not have it in Tasmania, but you have it in New South Wales

Prof. Smith —We have had it for about five years. We found the dropout rate for medicine was about 10 per cent before we did the interviews. It is now about one per cent.

CHAIR —That is very good.

Prof. Smith —One of the things we get out of the interviews is the bright kid who comes in and says, ‘I’m here because my mother said it’s what she wants,’ or ‘My father said he wanted me to do medicine. I don’t want to do it,’ and they fail the interview. Then we get nasty letters from the parents as to why their child failed the interview. We cannot actually say.

The other issue—and I guess this is putting the cat amongst the pigeons a little bit—is national assessment of graduates. There is a lot of that being kicked around at the moment. The US has gone to that. There are mixed views on that. If we have accreditation which is appropriate, then do we need it or not? That is an issue that we are going to have to face up to eventually—whether there is some sort of assessment at a national level.

CHAIR —So far that has not been part of these discussions?

Prof. Smith —No. I think we need to get the national registration matter sorted out first, and whether accreditation and registration are put together or not. They will still effectively function separately, because registration is about individuals and accreditation is about large organisations.

CHAIR —The previous witnesses spoke about the great increases in graduates over the last few years. We remember when there was real alarm and then people saying, ‘We’re now recruiting more but it’s going to take six to seven years to see that difference.’ In both your schools and amongst all the schools, is there an overapplication compared to those that are accepted?

Prof. Carmichael —Yes. There has always been, and it is still the case, that there are many more suitable applicants than we can accommodate.

Prof. Smith —We have 3,000 applicants for 200 Commonwealth supported places. The cut-off is 99-point-something. It is still ridiculously high.

Senator HUMPHRIES —Your number of enrolments would have dropped with the decision to end fee-paying student placements?

Prof. Smith —We were offered CSPs to compensate for that. We only took a few; I think we have nine or 10 full-fee-paying places.

CHAIR —You were not a big one, I know—New South Wales did not take it up heavily at all. Sydney did.

Prof. Smith —No. It has been an issue in Queensland because they probably took their numbers up to a greater extent—

CHAIR —They did.

Prof. Smith —and they were encouraged to do so at the time. And there is obviously the issue of those students tracking through. They are going to be supported, so I think that issue is dealt with. I think the issue at the moment is the number of students that are allowed in each of the schools. The other issue that we are addressing is coping with that increased number coming through and having adequate clinical placements for them. We believe this can be achieved, but it will be a big ask in the next two or three years when this peak is coming through the clinical years.

Senator BOYCE —One of the chair’s earlier questions prompted me to remember to ask you this, Professors. We had evidence earlier from the Nursing Federation and the nursing college that there is now an undergraduate nursing course being offered from a TAFE in Victoria. They expressed concerns not necessarily about the quality of the course but about this move into that area. Is your council aware of this move? Have you discussed it?

Prof. Carmichael —Not particularly, no. We do have discussions with the Council of Deans of Nursing, which is our counterpart body in the higher education sector. It is not something we have covered with them as yet. I am aware of that particular development.

CHAIR —No TAFE is doing medicine yet?

Prof. Smith —Not yet, no!

Senator BOYCE —Not that you know about, anyway!

Prof. Carmichael —Seeing the expansion we need at the moment, if there was the need for more places—and that indeed is a moot point looking ahead—then the universities that exist would be the places to look to to take them up rather than creating yet another provider. They are very resource intensive, and it is much easier to build on existing infrastructure that than create more infrastructure.

CHAIR —Sure, and it is a big investment to get the appropriate infrastructure.

Prof. Carmichael —Yes.

CHAIR —I do not know how we have done it but we have now managed to be before time instead of running over—it never ceases to amaze me! Thank you so much. When the bill is available—the best time frame we have been able to achieve at this stage is that it will be available as soon as possible—and you see it, you could well have further comment that you would like to make, and we will welcome that when it happens. Thank you very much.

Proceedings suspended from 2.48 pm to 3.15 pm