The Medical Board of Australia could be about to make a costly mistake. Regular testing of competency being introduced is not a matter of if, but when, said the new boss of the NSW Medical Council, Dr Greg Kesby, in an interview with Australian Doctor magazine.Dr Kesby also said there needed to be a process to instil confidence within the community that all doctors’ knowledge was up-to-date.
On the face of it, competency checks of doctors sounds appealing. I’m sure some politicians will love the rhetoric. But at the same time, alarm bells were going off when I read the interview.
Does Dr Kesby imply that the Australian public has lost confidence in its health practitioners? Are there concerns about the quality of Australian healthcare? There are many other unanswered questions too.
Is there any evidence that the current quality assurance systems, such as accreditation and CPD, are insufficient? Is recertification or revalidation — such as has been implemented in the UK — an efficient way to improve the quality of healthcare? Is it possible to design a system that reliably differentiates between good and bad practitioners? And how do we define competency?
Based on numbers from Canada, AHPRA estimates that 1.5% of Australian medical practitioners are performing ‘unsatisfactorily’. I’m not sure Canadian figures can be applied to Australia, but 1.5% of unsatisfactory performers in any group is low. There are numerous models: from strengthening CPD to targeting those at high risk of complaints, to the full-bore version rolled out in the UK. But if the board tries to identify these substandard doctors, carpet-bombing the whole profession is problematic.
One thing is for sure: UK-style revalidation is expensive. The process takes 1-2 working days per practitioner. Imagine thousands of Australian doctors having to take a couple of days off work to fulfil revalidation requirements.
Imagine the enormous effort it will take to manage this process. Think about the additional cost of the training, time and wages of the appraisers — who, I assume, will be doctors too — and the admin staff, extra regulation, log books, documents, IT etc.
According to the UK’s Pulse magazine, the revalidation of doctors has become a colossal enterprise, costing taxpayers £97 million (about $207 million) a year. This figure does not include revalidation of other health practitioners. Critics of the UK system have said it will not detect poor doctors, as its main purpose is to gain patients’ trust. Others feel it mainly serves to demonstrate what good practice looks like.
Policing the profession
A former UK GP-appraiser, now working in Australia, mentioned on the GPs Down Under Facebook group that appraisals used to be fun, interesting and mainly pastoral. Under revalidation, they became a form of policing the profession, he said.
Professor Kerry Breen, adjunct professor in the department of forensic medicine at Monash University, wrote in the Medical Journal of Australia last year that there was little evidence to support the idea of transposing the UK system to Australia.
He said that despite some local failures of medical regulation and hospital governance, the community had not lost faith either in its doctors or regulatory system. Indeed, it appears the public is largely content with its healthcare practitioners: Australian doctors, nurses and pharmacists have been in the top three most trusted professions for many years in the annual Roy Morgan research.
More recently, Dr Steve Wilson, an AMA WA representative, questioned in the AMA’s magazine whether revalidation would be able to address those who failed to practise to agreed levels. And if it did, he asked, would that be a sign of impairment or does it reflect personal style, or a lack of time, training, experience or adequate remuneration?
Don’t follow the UK
About 5000 doctors a year are considering leaving the UK, and many come to Australia. Bureaucracy is one reason they emigrate. Simply copying the UK’s revalidation system would be a big mistake. The last thing we need in Australia is more regulation, red tape and stressed-out doctors.
In recent years, our healthcare system has seen enough unsuccessful concepts not supported by evidence. Think about the super clinics program or the PCEHR, and the accompanying cost blowouts, delays and disappointing results.
It will be easier and cheaper to build on existing quality assurance systems.
Let’s look, for example, at refining CPD and accreditation. As they say, the main difference between a wise man and a fool is that a fool’s mistakes never teach him anything.
Developing an expensive new system with little or no supportive evidence failed in the case of super clinics and e-health, and it will fail with revalidation too.
This article was originally published in Australian Doctor Magazine.