Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697637402485.pdf (Australia)
SENATE COMMUNITY AFFAIRS REFERENCE COMMITTEE Inquiry into the medical complaints process in Australia Background to the Australian Medical Council submission The Australian Medical Council (AMC) is the independent national accreditation body for the medical profession, appointed under the Health Practitioner Regulation National Law.
It develops standards for the accreditation of medical programs and/or processes across all phases of medical education: university medical programs, intern training, specialist medical programs and continuing professional development.

It accredits programs and providers against these standards.
It also sets the standards for and administers the assessment of overseas trained medical practitioners for non-specialist (general) registration and accredits the processes for assessment of overseas trained specialists implemented by the specialist medical colleges.

The AMC accreditation processes aim to recognise medical programs and assessment processes that provide graduates with the knowledge, skills and professional attributes necessary to practise medicine safely and effectively in Australia.
As a standard-setting and accreditation body, the AMC is interested in:  Understanding the prevalence of bullying and harassment in the medical profession and/or health services and, as a consequence, understanding the effect on medical training and education and the wellbeing of trainees and students  Overcoming barriers to reporting and addressing bullying and harassment  Clarity concerning responsibilities in address professional misconduct allegations (including bullying and harassment),  Continuous improvement of the operation of the National Registration and Accreditation Scheme to improve health outcomes for patients, and support a world-class standard of medical care in Australia; Response in relation to the inquiry terms of reference a. the prevalence of bullying and harassment in Australia’s medical profession; [This is the overarching issue under inquiry.
The committee defines 'Australia's medical profession' as including both nurses/midwives and medical practitioners (doctors), as well as students for those professions] The AMC strongly supports better mechanism to understand the prevalence of bullying and harassment.

Through its accreditation processes the AMC has some exposure to the serious and pervasive issue of bullying and harassment in the medical profession, as well as efforts made by institutions and individuals to address it.
The true prevalence of bullying and harassment is difficult to quantify.

However work has been undertaken to establish the extent and severity of this problem through a number of enquiries including: o The September 2015 review conducted by the Expert Advisory Group on Discrimination, Bullying and Harassment, which reported to the Royal Australasian College of Surgeons.
Medical complaints process in AustraliaSubmission 57 The report provides statistics for surgical specialties in relation to Fellows’, trainees’ and international graduates’ experiences of discrimination, bullying and harassment, and the effectiveness of current mechanisms at satisfactorily resolving such instances.
o Health Services as employers would have data on complaints through their human resources processes which may be helpful in attaining a broader picture of this problem across the completeness of these processes.

the profession, although as noted below, there are concerns about o As the accreditation authority for medicine, the AMC surveys doctors in specialty training about the quality of their training.
The survey asks about mechanisms to raise concerns about training and supervision, and issues, such as bullying and harassment, and trainee wellbeing and seeks submissions for doctors in training groups about these matters.

The AMC surveys the doctors in training (and supervisors) as it completes the accreditation assessment of the relevant specialist medical college.
Because of the cyclical nature of accreditation, this means it is gathering national feedback every year but feedback on a specific specialist program only every 6 or 10 years (depending on the period of accreditation granted).
o There are more than 20,000 doctors in specialty training, and the AMC believes all 16 of the specialist medical colleges are undertaking work to determine the extent of bullying, discrimination and sexual harassment experienced by the doctors in training in their specialist medical program.
In 2015, the AMC completed a review of the Standards for Assessment and Accreditation of Specialist Medical Education Programs and Professional Development Programs, which are used to assess whether specialist medical programs and the colleges that provide the programs produce graduates with the knowledge, skills and professional attributes necessary to practise medicine in Australia.

The revised standards have an increased focus on trainee wellbeing.
New standards require specialist medical colleges to promote a supportive learning environment for doctors in training, and to collaborate with other stakeholders, especially employers, to identify and support trainees who are experiencing personal and/or professional difficulties that may affect their training.

The standards also require colleges to take account of the health, welfare and interests of trainees when they accredit health services as training sites.
The revised standards have been implemented from 1 January 2016 and all the specialist medical colleges have been asked to indicate how they are addressing these new standards, and are establishing processes to gather the data necessary to assess the issues for their medical specialty.

A document listing the relevant accreditation standards is provided at attachment 1.
The AMC is now reviewing the standards for other phases of medical education and training, including medical school and the first year of work post-graduation, the internship.
It will strengthen these standards in the same way as the standards for specialist medical education and training The AMC has proposed a national training survey as one approach to gather independent annual data on the training experience of doctors in training, including their direct experience of or witnessing of bullying, discrimination and sexual harassment.
b. any barriers, whether real or perceived, to medical practitioners reporting bullying and harassment; [Is there anything preventing medical practitioners from reporting bullying and harassment?]

In its report to the Royal Australasian College of Surgeons, the Expert Advisory Group outlines the issues surrounding the underreporting of bullying and harassment.
Fellows, doctors in training and international medical graduates are reportedly very reluctant to speak out for a number of reasons, but most commonly due to a fear of reprisal.

The AMC’s experience as an Page | 2 Medical complaints process in AustraliaSubmission 57 accreditation authority confirms this reluctance.

The real risk to future career prospects significantly inhibits victims from reporting incidents.

This is not unique to medicine.


These concerns may warrant consideration of the introduction of an independent oversight mechanism for complaints to be raised and addressed, such as an ombudsman role.

The report by the Expert Advisory Group also notes inadequacies in relation to complaints handling and conflicts of interests by the hospitals overseeing such processes as further weakening victims’ ability to report abuse and achieve a satisfactory resolution.
There is a further concern that there is a lack of appropriate consequences for perpetrators.
c. the roles of the Medical Board of Australia, the Australian Health Practitioners Regulation Agency and other relevant organisations in managing investigations into the professional conduct (including allegations of bullying and harassment), performance or health of a registered medical practitioner or student; [Are the complaints and investigation processes of the relevant medical boards, nursing and midwifery boards and AHPRA able to be used vexatiously for bullying or harassment, particularly by other medical professionals?]
The AMC does not have close involvement in the formal processes under the National Law for investigations concerning the professional conduct of an individual practitioner or student, but does have some insight into the foundational issues.

It also recognises that, following the review of the National Registration and Accreditation Scheme in 2014, changes to these complaints processes are being pursued through legislation and through the Australian Health Practitioner Regulation Agency.
While notification and complaints processes will always be necessary to address allegations concerning unprofessional behaviour in individual practitioners, this tends to apply once problem behaviour is well established and persistent.

The AMC sees that it is necessary to increase efforts to detect bullying, harassment and other cultural problems within the medical profession both at a systems level so that issues of culture can be addressed as well as at the level of the individual practitioner.
If there is to be significant profession-wide improvement, a more proactive approach is needed to systematically address the roots of this problem in the Australian medical profession.

In the medical training and education system in Australia and New Zealand, both the formal education providers and the health services have roles in setting standards for and delivering training and education, and doctors in training can be unclear about where to address complaints.
In addition to strengthening the accreditation standards for medical programs, the AMC has also strengthening its own processes for complaints against education providers and organisations accredited by the AMC.

These complaints may relate to any systemic matter that may indicate that the accreditation standards are not being met, including the standards relating to trainee wellbeing, and processes to address bullying, discrimination and sexual harassment.
Australian National Training Survey The AMC supports the introduction of a national training survey as a means of gathering better data about the quality of medical training in Australia.

This mechanism is well established in the United Kingdom, where a national training survey is used to gather confidential feedback on training programs and providers.

The survey is managed by the regulator, the General Medical Council, which makes reports on survey findings publicly available.
The organisations that oversee and provide training in the UK review the detailed data and are expected to use the findings to improve their own approaches.

The General Medical Council, acting as the accreditation authority, checks through its quality assurance processes that issues are addressed by individual providers and, through thematic enquiries, across the medical training system.
Page | 3 Medical complaints process in AustraliaSubmission 57 The GMC online survey has a set of core questions which test trainees’ perceptions of providers’ compliance with GMC standards, and specialty specific questions set by Royal Colleges and Faculties which test their perceptions of the quality of delivery of the curricula, and their experience of undermining behaviours, including bullying.
In 2015, the survey was completed by about 53,000 doctors in training (more than 95% of those eligible to complete).

The GMC has demonstrated the effectiveness of this independent mechanism in identifying concerns in particular locations and particular specialties, and requiring those concerns to be addressed in quality assurance processes.
More information is available on the GMC website: http://www.gmc-uk.org/education/surveys.asp The plan for a National Training Survey in Australia originated from the Australian Medical Association (AMA), whose Federal Council had resolved: That Federal Council, in-principle, supports a national training survey of prevocational and vocational training based on the following principles:    it provides robust data to support quality improvement of medical training; it is overseen by the AMC; is developed in cooperation with the AMA, Confederation of Postgraduate Medical Education Councils and medical colleges; the data is collected as part of the medical registration process, although the data should not be retained by Australian Health Practitioner Regulation Agency; the data is published annually; and that the AMA should work with the AMC and relevant stakeholders to progress the concept of a national training survey.
   The AMC and the AMA hosted a meeting in February 2013 to discuss the proposal and explore interest in further work on this.

Representatives of the Department of Health and Ageing, the Medical Deans, Committee of Presidents of Medical Colleges, Confederation of Postgraduate Medical Education Councils and General Practice Education and Training attended the meeting.

While there is support for this initiative, developing a governance structure and determining a funding source or sources is necessary.
The AMC notes that the 2015 report of the national review of medical intern training http://www.coaghealthcouncil.gov.au/Portals/0/Review%20of%20Medical%20Intern%20Trainin g%20Final%20Report%20publication%20version.pdf also supports the proposal for a national training survey.
d. the operation of the Health Practitioners Regulation National Law Act 2009 (the National Law), particularly as it relates to the complaints handling process; [Does the legal framework under which the relevant medical boards and AHPRA operate have appropriate safeguards against being used vexatiously for bullying or harassment?]

These issues were addressed in the 2014 Independent Review of the National Registration and Accreditation Scheme.
e. whether the National Registration and Accreditation Scheme, established under the National Law, results in better health outcomes for patients, and supports a world-class standard of medical care in Australia; [Has nationalising the registration and monitoring of medical practitioners improved medical care in Australia?]
Page | 4 Medical complaints process in AustraliaSubmission 57 As prescribed by the National Law, a key objective of the National Scheme is to provide for the protection of the public by ensuring that only health practitioners who are suitably trained and qualified to practice in a competent and ethical manner are registered.
In contributing to this inquiry, the AMC draws attention to systemic improvements that have been achieved as a result of the National Registration and Accreditation Scheme which operates under the National Law, and key strengths in its design that contribute to more explicit standards for accreditation of education and training programs across the 14 regulated health professions, and more accountable processes for accreditation of programs, so that this key objective can be met.
Of reference to the strengthened role of accreditation under NRAS, particularly influential factors include:   the establishment of a legislative basis for all accreditation activities under the National Law; the enhanced effectiveness of accreditation functions at providing quality assurance and supporting continual improvement in the training and education of health practitioners, including through: o powers to set conditions on the accreditation of institutions where standards are not fully met; o powers to continually monitor the performance and implementation of accreditation conditions placed on institutions;  the continued independence of the accreditation functions, which strengthens the ability of accreditation authorities to act on concerns and complaints.
The capacity to set and monitor providers against the new standards described in Attachment 1 is one of these developments.

The National Scheme is still relatively new, and the detailed data capture and analysis necessary to answer this question is still in early stages.

The AMC commends work by the Australian Health Practitioner Regulation Agency to develop its capacity to undertake this work.
f. the benefits of ‘benchmarking’ complaints about complication rates of particular medical practitioners against complication rates for the same procedure against other similarly qualified and experienced medical practitioners when assessing complaints; [Should there be stronger requirements for patient outcome specific data to be used both in lodging and investigating complaints?]
Nil response g. the desirability of requiring complainants to sign a declaration that their complaint is being made in good faith; and [Is there evidence to suggest vexatious complaints are being made, and if so, what systems could be put in place to reduce the prevalence?]

Nil response Should the Committee require further information the AMC would welcome an opportunity expand on the comments in this submission.
Page | 5 Medical complaints process in AustraliaSubmission 57 Ian Frank AM Chief Executive Officer 2 November 2016 Page | 6 Medical complaints process in AustraliaSubmission 57