Issues Facing Australian GPs

Dr John Goswell, General Practitioners of Australia

Revalidation is the process of ensuring that doctors are fit to practice medicine. The Australian Health Practitioners Regulation Authority (AHPRA) is engaged in the process of forcing revalidation upon the Australian medical community.

If you have followed the process on the AHPRA website (which you may not have because it was hard to find), you will note the issue has not been whether revalidation should occur but rather in what form. The process to date is summarised at GPA Current Issues. The process has been an open and transparent one but GPs may have difficulty in recalling the notification document sent out by AHPRA. However, there has been little reaction of any kind from the medical community. AHPRA has called for submissions to comment on the proposed revalidation scheme.

As of late November there have been seven submissions from medical organisations about the scheme. Thirty one individual doctors have also made submissions. One might interpret this limited response as tacit submission to a process that will have dramatic effects on the way that we work and our future finances.

So what is the problem?

Some doctors are under-performing. There is nothing new about that. It has been happening since the term doctor was coined. We all under-perform at times, e.g. after working 60 hours straight, when we have influenza but feel obliged to keep seeing patients, when major stresses occur at home.

The proposed model for revalidation will do nothing to address that. There is no suggestion of banning long shifts for interns and CMOs. No talk of providing emergency assistance for doctors in need. No talk of finding a system of providing affordable locums for doctors who have not had holidays in five years. Instead it aims at "fixing" those who consistently under-perform.

But how to do that?

In the UK, revalidation took the form of thorough peer assessment, with validators coming to the surgery to interview the candidate, watch his/her work and review his/her notes. Not surprisingly the system has met with much disfavour. Record numbers of English doctors are leaving the system¹.

The UMbRELLA interim report², which reported on the UK model at the three year mark, has been released without providing any real figures to support the usefulness of the program (i.e. how many doctors were found to be under-performing). There is little evidence to date that revalidation has succeeded in its aims. In short, the one third of the billion dollar program appears to be a dismal failure.

How big is the problem AHPRA is trying to fix?

AHPRA has commissioned a report into revalidation in Australia. The interim report of the Expert Advisory Group on Revalidation (EAGR)³, quotes figures from overseas as there is supposedly no good Australian data. It is hard to determine if any of these reports provide useful information about the Australian health care system.

There is Australian information available, however. In 2013 Bismark et al, (Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia) examined all the complaints recorded against medical practitioners across Australia over an approximately 12 year period (2000 to 2011 inclusive). The total comprised 18,907 complaints against 11,148 doctors. This represents an average of 1,576 complaints per year against an average of 929 doctors. These 929 doctors represent 1.7% of the medical workforce. Complaints requiring prosecution were significantly lower.

The major finding of this study was that repeat offenders were likely to offend again. Someone with 10 complaints against his/her name had an almost 100% chance of getting another complaint within 2 years. This means that the best way of preventing problems is to do something with the repeat offender. The high recurrence rate is a demonstration of the failure of both the doctor and the system to effectively address a recognised problem.

The NSW Health Care Complaints Commission (HCCC) 2016 report suggests about 100 doctors were sent to court. This represents 0.03% of the NSW medical workforce. The report states than in total there were 4,350 complaints against 2,134 medical practitioners (6%). A percentage of the claims were vexatious, or against the practice or non-medical staff, or were about fees or waiting lists.

Many complaints are addressed by individual practices and their GPs and most do not reach the HCCC. Little is known about the frequency of these complaints or whether the response from the general practices are usually satisfactory. AHPRA would be well advised to determine the magnitude of the problem and effectiveness of current dispute resolution processes before imposing a crude, cumbersome, bureaucratic and expensive solution upon the profession.

There is a clear case to avoid the full UK scheme.

Most recommendations are for a modified system that targets high risk groups. These are solo doctors, those working isolated from peers, older doctors, those from certain overseas countries, and those who work long hours. Unfortunately these parameters clearly target rural GPs.

Most rural GPs are highly skilled generalists. Those without these skill stay in the cities. They would not cope in the bush.

The current proposal will burden the rural generalist with more red-tape and more hurdles to clear in order to continue to practice. This is not a formula for attracting urgently needed doctors to the bush.

What is the cost of this program?

We can be sure that when the form of revalidation has been determined, there will be a cost. No mention has yet been made as to who will pay. The choices are Consolidated Revenue or the profession. Recent experience does not bode well for the professions' pockets.

Revalidation is not a cure all. It will not identify doctors acting criminally or unethically. It does not address over-servicing or inefficient care. There are better ways of achieving better health care and improving the care provided by all doctors not just those who are under-performing.

The cost is not just measured in dollars. Every hour per week dedicated to bureaucratic paperwork is the equivalent of removing 1,800 doctors from the workforce. Diminishing GP morale means that some doctors will retire early and some will leave for overseas.

Current monitors

We currently all undergo multi-sourced assessment. Medicare monitors practices through item numbers. The National Prescribing Service gives us feedback on our prescribing. Continuing medical education requirements ensure we are continuously updating our skills and knowledge.

Through these programs we are up to date with CPR (RACGP members) or ALS (ACRRM fellows). The Australian Childhood Immunisation Register monitors our immunisation rates. Many practices use the Pen tool or similar for the assessment of other common general practice problems. Those of us who teach registrars come under the close scrutiny of young eyes. Accreditation looks at our practices and samples our medical records.

It seems never-ending. The next set of RACGP standards may well have us examining our navels for conformity.

There are already a number of safeguards in place. Patients can easily give feedback through the mandatory suggestion boxes in each practice. They can easily complain to the HCCC. They have the ability to go through civil courts where major issues have occurred. Doctors are now legally required to report colleagues whose medical practice puts patients at risk.

Conclusion

Australia enjoys one of the best medical systems in the world. It provides good value for the taxpayers' dollar. The costly failure of revalidation in the UK is now well recognised and there is little evidence that revalidation actually works.

What we do know is that revalidation will cost more. It will be an increased burden upon some, if not all doctors. It will increase red-tape and it will reduce morale.

It could be likened to using a new, untested drug on a disease that we are fairly sure exists but cannot properly document. There will be side effects and it will be expensive, but we should give it a go because we think it will work! Once started we may not be able to tell for sure that it does work, but since there was general consensus that something had to be done (for the problem that we thought probably existed), we will continue.

Thus, a clearer understanding of this professional quality assurance issue and a study of the most effective solutions are needed before embarking on a costly, bureaucratic process that will be damaging to the profession and ultimately our patients.