21 October 2017
Dr Ayman Shenouda
Health Education Accreditation
No case for change
Australia enjoys an enviable reputation as a provider of high-quality medical education and training. We have built a strong reputation for excellence and quality through a system of Australian Medical Council (AMC) led accreditation standards. A system that upholds patient safety and quality of care through high-level and targeted policy whereby accreditation indicators can be applied consistently has been key to our success. Yet the recent consultation with the release of a discussion paper as part of a Government-commissioned review into the accreditation systems suggests we have a system in need of strong repair.
The key shift proposed in the draft report involves the formation of more centralised control through a new Health Education Accreditation Board with an equally strong remit.
These would include:
The need to pursue such significant change at this time has confused many from within the sector. The specialist medical colleges through the Council of Presidents of Medical Colleges (CPMC) released a response early in the consultation. The Australian Doctors Federation (ADF) and Australian Medical Association (AMA) followed with strong resistance to such significant change to a system which is working well. All seem to agree that the key shift proposed in this paper would see the AMC’s role weakened leading to a dilution of standards and patient care. It would most certainly see unnecessary controls imposed on the specialist medical colleges.
Alignment or more bureaucracy
Major reviews usually share some common factors and this one is certainly not unique. These include the need for strengthened systems to improve outcomes and in driving efficiencies. It is a need for streamlining and alignment that make their way into most of these discussions. This in turn almost always means more government control.
The Accreditation Systems Review report states a need for alignment but then offers additional layers of bureaucracy to achieve it. It recommends increased government control over health professional education and training through the removal of the independence of the regulator. There is also a proposal to give the health ombudsman jurisdiction over specialist colleges particularly in relation to decisions around International Medical Graduates (IMGs).
Making a case for change
These key shifts are being floated as policy solutions ‘to ensure that the educational programs provide a sustainable registered health profession workforce that is flexible and responsive to the changing health needs of the Australian community’.
It is difficult to see how a large bureaucracy will drive system efficiencies and why you would seek more alignment beyond what already exists for medical education through the AMC. Specialty-specific requirements aligned towards patient need are key to determining quality outcomes. This expertise resides from within the specialist colleges and the AMC and will not be found through a bureaucracy-led board without any clinical discipline authority.
The draft paper seeks to introduce changes which really just stem out of a Productivity Commission Review undertaken more a decade ago. Given this review is being led by the same independent reviewer that’s not all that surprising. But it’s clear that much has happened since 2005 which gives, even more, reason for those ideas that were rejected once to be rejected now.
The draft report outlines the case for ‘Reforming governance – the overarching model’ presenting 3 options with their option 3 being the preferred model. Interestingly, all the recommendations within the chapter steer us toward this preferred option or model. It also includes a diagram of the model which does very little to clarify the role of the AMC in this new preferred structure.
It’s clear the discussion omits the fact that the AMC has led some significant reforms to provide a quality framework which delivers an outcomes-focussed approach to accreditation. This may be unintended but it is most relevant to many parts of the governance discussion.
In the last three years, the AMC committed itself to national and international review, to build on its strengths and develop and implement a range of new activities. Revised standards for specialist program accreditation were rolled out after a two-year review and consultation effort. Progressing the evaluation and deployment of a new accreditation management system that sees a more streamlined accreditation processes.  None of these get a mention yet they have been implemented to achieve many of the very aims outlined in this discussion. The fact is that the AMC has already implemented outcomes-based standards and it is working towards a more streamlined system.
Delivering a more responsive health workforce
Building on the recent AMC-led reforms through encouraging more inter-professional team-based learning is now key. Alignment can certainly be achieved through a stronger multidisciplinary approach and there remain plenty of barriers in the training system limiting us here. The report makes some good points around this issue. Ensuring our health workforce is more responsive to emerging health and social care issues and priorities through encompassing a stronger team-based approach is precisely where we need to focus our efforts now .
Driving key workforce priorities through our accreditation system through some of those key enablers identified throughout the report should be pursued. These include more use of simulation-based education and training in the delivery of programs of study as well as making mandatory the inclusion of inter-professional education in all accreditation standards. This more team-based approach to learning is most important enabling service alignment and it would be good to see it formalised in some way.
The other really important area for workforce policy is the requirement that clinical placements occur in a variety of settings, geographical locations and communities, with a focus on emerging workforce priorities and service reforms. This is particularly important to rural and remote communities and together with current workforce planning mechanisms will help ensure we can address unmet need. It will help build a rural GP generalist workforce prioritising essential rural advanced skill areas, procedural and non-procedural, in response to service and skill deficits. If planned appropriately – in prioritising skill need – then these shifts will help to rebalance training it current acute setting focus. This will help to prioritise funding to ensure more community-based exposure strengthening these service solutions over time which will bring about those required service reforms.
After deciding stakeholders needed a little longer to absorb the long draft report, an extension was granted with submissions having just closed (16 October). It will be interesting to see how this discussion evolves before a final report is considered by COAG Health Minister at their next Ministerial Council meeting in November. I think on many aspects this review failed to make the case for major reforms to governance particularly in light of the changes already implemented from a medical training perspective by the AMC. The real opportunity here is to build capacity from within the current structure to align skills to workforce need towards a more integrated national training solution.
In prioritising what needs to be done it is important to realise that we have an accreditation system which is working well. There is good reason why the AMC is internationally recognised for its work. We have the highest possible standards of medical education, training and practice already in Australia. The specialist colleges are key to ensuring we keep it that way through the delivery of high-quality specialist training. They also play a vital role in providing national oversight and consistency to medical specialist training. More dialogue was most certainly warranted before presenting such significant shifts. I hope the discussion moving forward brings a more balanced perspective encompassing the many areas of reform already achieved to build on these areas in ensuring a future workforce responsive to need.
 CPMC. Media Release. Australian Medical Regulation Must Remain Independent. Council of Presidents of Medical Colleges 2017. Available at: https://cpmc.edu.au/media-release/australian-medical-regulation-must-remain-independent/
 AHMAC. Australia’s Health Workforce: strengthening the education foundation. Independent Review of Accreditation Systems within the National Registration and Accreditation Scheme for health professions.Draft Report September 2017. Australian Health Ministers’ Advisory Council 2017. Available at: http://www.coaghealthcouncil.gov.au/Portals/0/Accreditation%20Review%20Draft%20Report.pdf
 Productivity Commission 2005, Australia’s Health Workforce, Research Report, Canberra. Available at: http://www.pc.gov.au/inquiries/completed/health-workforce/report/healthworkforce.pdf
 AMC. Annual Report 2016. Australian Medical Council Limited. 2016. Available at: http://www.amc.org.au/files/656a1621bae0b8baaabca9e3ada8280a1dcbd38f_original.pdf
Dr Ayman Shenouda