MEDICAL PRACTICE ACT 1994 VICTORIA NATIONAL COMPETITION POLICY REVIEW FINAL REPORT March 2001 Contents Executive Summary 1 2 3 4 Review Objectives NCP Panel and Review Process The Medical Services Market, the Objectives of the Act and Market Failure Legislative Restrictions on Competition in the Medical Practice Act 1994 4.1 Registration Restrictions 4.1.1 Background 4.1.2 Findings and Recommendations 4.2 Provisions that regulate advertising by registered medical practitioners 4.2.1 Background 4.2.2 Findings and Recommendations 4.3 Accreditation of Intern Training Positions by the Medical Practitioners Board 4.3.1 Background 4.3.2 Findings and Recommendations 4.4 Powers for Board to require professional indemnity insurance 4.4.1 Background 4.4.2 Findings and Recommendations 5 6 Summary of Costs and Benefits References Executive Summary The Medical Practice Act was passed by the Victorian Parliament in 1994. The Act establishes the Medical Practitioners Board of Victoria and provides for the registration of medical practitioners and regulation of their standards of practice. As of 1st September 1998 there were approximately 14,500 medical practitioners with general registration in Victoria. A Departmental review of health practitioner regulation completed in 1990 recommended a consistent approach to registration across all health occupations. Since it was enacted in 1994, the Medical Practice Act has provided a model for review of all other health practitioner registration Acts. The review of the Medical Practice Act has been undertaken in accordance with the Guidelines for Review of Legislative Restrictions on Competition as required under the National Competition Policy and as part of the Department of Human Services' rolling program of review of health practitioner regulation. Terms of Reference for the review were approved in March 1998. The NCP panel identified a number of existing legislative provisions in the Medical Practice Act that might impede competition. These were of two types, professional registration provisions in the form of restriction on the use of professional titles, and restrictions on advertising by registered practitioners. A public discussion paper was released in October 1998', following a series of consultation meetings with key stakeholders. Over 160 submissions were received during November and December 1998. Following the election of the Labor Government in September 1999, a further round of consultations was held with key stakeholders, including the AMA (Victorian Branch) and the Medical Practitioners Board of Victoria. This report contains the findings and recommendations of the National Competition Policy Panel convened to conduct the review. In response to the NCP panel's recommendations in March 1999, the Government introduced into the Victorian Parliament the Health Practitioner Acts Amendment Bill 2000. The Act was passed in May 2000. The purpose of the Act was to amend the Medical Practice Act 1994 to update its provisions and implement the recommendations of the NCP Panel. A number of restrictions on competition have been retained or introduced in the amended Medical Practice Act 1994 following passage of the Health Practitioner Acts Amendment Act 2000. These are: • • • • Power for the Board to register those medical practitioners who have the required qualifications as specified by the Board. Restriction on persons who are not registered from using the title 'registered medical practitioner' or any other title calculated to induce a belief that they are registered. Limited advertising restrictions on registered medical practitioners. Powers for the Board to require registrants to provide evidence of satisfactory arrangements for professional indemnity insurance as a condition of registration. The NCP Panel recommended that protection of title continue to be the main form of legislative restriction in the Medical Practice Act. No legislative restrictions on the practice of medicine were recommended. The Panel recommended retention of provisions that prevent persons being registered under the Act as medical practitioners unless they have achieved the qualifications recognised by the Medical Practitioners Board of Victoria and have provided the information required by the Board for registration. Unregistered persons are unable to: • • assume the title 'Registered Medical Practitioner'; or hold themselves out as qualified and registered, including adopt any other title calculated to induce a belief that they are registered. Unprofessional advertising by medical practitioners can contribute to the increasing cost of provision of health services by promoting unnecessary treatments and increasing the associated risks of adverse events. The NCP Panel recommended restrictions on advertising designed to prevent unprofessional advertising by registered medical practitioners. The Panel formed the view that reliance on consumer protection and fair trading laws to regulate advertising of medical services did not provide sufficient protection to the public and that there was a net public benefit in empowering the Medical Practitioners Board to regulate this activity of medical practice. In addition, the Panel recommended implementation of the Victorian Law Reform Commission recommendations to empower the Board to require professional indemnity insurance as a condition of registration. 1. Review Objectives The Medical Practice Act was passed by Parliament in 1994. It has provided a model for review of all other health practitioner registration Acts since that time. The Act protects the public by setting up the Medical Practitioners Board of Victoria and establishing statutory powers for the Board to regulate the profession. The Board is responsible for maintaining high standards of medical education and practice, as well as providing a mechanism for consumers to have any complaints against individual practitioners addressed. In 1995 the Victorian Department of Human Services commenced a review of all practitioner registration legislation in Victoria. The National Competition Policy review of the Medical Practice Act was commenced in 1998 in conjunction with the NCP review of the Nurses Act 1993. The review was conducted in accordance with the 'in house review' model as described in the Victorian Government Guidelines for Review of Legislative Restrictions on Competition.(StzX.e Government of Victoria, National Competition Policy Guidelines, pp.4). Terms of reference for the review are contained in Attachment 1. The review addressed broader issues in addition to the restrictions identified under NCP. The four main objectives of the review were: 1. To ensure that the Victorian Government was able to meet its obligations under the Competition Policy Agreement, that is, to review and remove any unnecessary barriers to competition in Victorian legislation. Specifically, to re-examine within the context of National Competition Policy, the restrictions on advertising that have been incorporated into all new health practitioner registration Acts since 1994. To ensure that all health practitioner registration Acts contain a common core set of provisions governing the provision of health services by individual health practitioners as well as procedures for handling complaints and discipline. To present for comment changes to the legislation proposed by the Medical Practitioners Board of Victoria. 2. 3. 4. Objective 1: Under National Competition Policy, Victoria was required to review all existing legislation that imposes restrictions on competition by the year 2000. As part of this process, the Department of Human Services was required to review and, where necessary, reform all existing legislative restrictions on competition contained within health practitioner registration legislation administered by the Department. The guiding principle of the review was that legislation should not restrict competition unless it could be demonstrated that: • • the benefits of the restriction to the community as a whole outweigh the costs, and the objectives of the legislation can only be achieved by restricting competition. Restrictions on competition were identified in the Medical Practice Act and these were assessed against the above principles. Objective 2: One of the restrictions on competition that was identified was the regulation of advertising by registered medical practitioners. The advertising provisions in the Medical Practice Act have been used as a model for all health practitioner registration Acts passed in Victoria since 1994. By issuing the discussion paper, and making it widely available to all interested parties including other health practitioner registration boards and their respective constituencies, the Department flagged its intention to review the standard provisions in health practitioner registration Acts which regulate advertising. It was expected that, if changes were to be recommended to the advertising provisions in the Medical Practice Act, as a result of this review, then amendments may also be required to all existing health practitioner registration Acts, to ensure consistency, and compliance with National Competition Policy. Objective 3: The Medical Practice Act, along with the Nurses Act 1993 was one of the first Acts passed consistent with the Victorian model of health practitioner legislation. Therefore, it already contained the standard modern provisions required for all health practitioner registration legislation in Victoria. However, the review required under NCP provided an opportunity to: • • reassess the standard provisions with a view to ensuring that they will satisfactorily support and regulate practice into the 21st century; assess whether incremental changes that have been introduced with the passage of more recent health practitioner registration should be applied to nursing and medical practice legislation. More recent Acts with a number of updated provisions were the Chiropractors Registration Act 1996, the Osteopaths Registration Act 1996, the Optometrists Registration Act 1996, the Podiatrists Registration Act 1997 and the Physiotherapists Registration Act 1998. Objective 4: The Medical Practitioners Board of Victoria proposed a number of amendments to the Medical Practice Act 1994. It was important that interested parties have an opportunity to examine and comment on these proposals. If such proposed amendments were to be adopted, then they would be expected to form part of the standard health practitioner registration model and other Acts might also require amendment. 2. NCP Panel and Review Process1 A National Competition Policy Review Panel (NCP Panel) was set up to meet the requirements of the Victorian Government's National Competition Policy Guidelines. The panel consisted of three persons who were neither directly engaged in the medical profession nor in the regulation of that profession. They were: Mr Robert Doyle MP then Parliamentary Secretary to the Minister for Health then General Manager Public Health & Development Division Department of Human Services then Project Manager, Health Workforce Section Public Health & Development Division Department of Human Services Ms Jan Norton Ms Anne-Louise Carlton The NCP Panel was responsible for conduct of the review and consultation, with advice and assistance from the Legislation and Legal Services Section of the Department of Human Services. The review model determined under the Guidelines for Review of Legislative Restrictions on Competition was Level 4: In-House Review with a low scale/priority and no minimum consultation requirements. However, due to the potential for this review to establish precedents for amendments to other health practitioner registration Acts (see Objective no. 3), release of a discussion paper and conduct of a public consultation process were considered necessary. In October 1998, the NCP Panel released a public discussion paper addressing the reviews of both the Medical Practice Act 1994 and the Nurses Act 1993 and advertisements were placed in The Age inviting submissions from the public. The paper was also available on the Internet (See Attachment 1). The purpose of this paper was stated as: • To outline the guiding legislative principles of the National Competition Policy, to identify and review the restrictions on competition contained within the Nurses Act 1993 and the Medical Practice Act 1994, and in particular, to examine whether there is a need for continued statutory registration of these professions, and how advertising should be regulated. If there is a sufficient case for continued statutory registration of nurses and medical practitioners, then to: => Re-examine the model of legislative review that has been applied to health practitioner registration legislation in Victoria. => Identify any changes introduced to the model of health practitioner registration since passage of the Nurses Act 1993 and the Medical Practice Act 1994. => Provide an opportunity for those who have an interest in the practice of nursing and medicine to comment on any proposed amendments prior to the preparation of separate draft bills. • The discussion paper set out: • National Competition Policy considerations (Section 2). • The key features of the model of regulation of health practitioner groups adopted by the Victorian Government, and any changes that have been introduced to the model since passage of the Nurses Act 1993 and the Medical Practice Act 1994 (Sections 3 and 4). • The implications for the Nurses Act 1993 and the Medical Practice Act 1994 of recent changes to the standard model of health practitioner regulation. (Section 4) • The reforms recommended by the Nurses Board of Victoria and the Medical Practitioners Board of Victoria (Section 5). • The process of consultation, including how interested parties could obtain copies of this discussion paper and comment on the proposed reforms (Section 6). The discussion paper summarised the main areas proposed for reform. In addition, submissions on matters not directly raised but which fell within the scope of the review were encouraged. The key stakeholders involved in the consultation process included: • • • • • • • Consumers of medical services Members of the medical profession The Medical Practitioners Board of Victoria AMA (Victorian Branch) Specialist medical colleges Hospitals, nursing homes and other health service providers Members of other health professions and their representative bodies. Over 160 submissions were received and a summary of these submissions is contained in Appendix 1. Following receipt of the NCP Panel's recommendations in March 1999, the Health Practitioner Acts Amendment Bill 2000 was prepared for introduction into Parliament. Following the election of the Labor Government in September 1999, a further round of consultations was held with key stakeholders, including the AMA and the Board. The Health Practitioner Acts Amendment Act was passed by the Victorian Government in May 2000, giving effect to the recommendations of the NCP review and other recommendations about changes to the model health practitioner registration provisions. 3. 3.1 The Medical Services Market, Objectives of the Act, and Market Failure The Medical Services Market The Australian Institute of Health and Welfare publishes data on the characteristics of the medical labour force in its National Health Labour Force Series. In terms of overall numbers, the Australian medical labour force in December 1998 comprised 49,623 practitioners of whom 48,934 were employed and practising in medicine. Of this number, 12,074 were identified as practising primarily in Victoria. (Medical Labour Force Report No. 16 1998). As at 1st September 1998 there were approximately 14,500 medical practitioners holding general registration in Victoria. Of the employed practitioners in Australia, 46,078 were clinicians and 2,857 were in nonclinical roles as administrators and educators, and in public health and occupational health. Of the clinicians, 20,1852 (45.3%) were primary care practitioners, 4,263 (9.3%) hospital nonspecialists, 16,490 (35.8%) specialists and 4,473 (9.7%) specialists-in-training. The hospital non-specialist workforce is largely composed of doctors in training positions with currently 1,098 (25.8%) of them choosing hospital work as a career. A continuation of the postgraduate training pattern is expected to gradually decrease the proportion of primary care practitioners in the medical workforce and increase the proportion of specialists. (Medical Labour Force Report, pp 1). The number of clinicians per 100,000 population was 244.5 in 1998. This compares with 209.5 in Canada in 1998 and 218.7 in New Zealand in 1997. There were 243.4 clinicians per 100,000 in Victoria, with a difference of 26.8% between the States and Territories with the lowest and highest supply. There were 87.5 medical specialists per 100,000 in Australia, with 96.6 in Victoria. (Medical Labour Force Report, pp 2). Of the 5,316 primary care practitioners identified as practising in Victoria, the majority (4,500) were working in private rooms, with 459 in acute care hospitals, and smaller numbers in non-residential private facilities, aboriginal health services, other residential facilities, educational institutions and the Defence forces (Table 11). 4,817 were working in general practice, with 499 in a special interest area (Table 13). Of the 4,539 medical specialists practising in Victoria, the main specialties were Internal Medicine (1,143), Surgery (808), Psychiatry (628) and Anaesthesia (537). (Medical Labour Force Report, Table 16). Examination of overseas trained doctors is conducted at the national level by the Australian Medical Council. In 1998, 669 overseas trained doctors presented to the Australian Medical Council for examination, and 220 successfully completed both the multiple choice questions and clinical components of the examination process (Medical Labour Force Report, Table 33). With the addition of 59 overseas trained practitioners accepted for registration via the specialist college pathway, a total of 299 additional doctors entered the medical workforce through this pathway. There were 2,198 temporary resident doctors who entered Australia for employment in 1998. Most entered for a stay of less than 12 months. Of those 223 re-registered for practice at general renewal in late 1998. In 1998-99, there was an average of 10.87 Medicare services provided per head of population, with 5.4 of these by general practitioners and 1.96 for pathology tests (Medical Labour Force Report, Table 41). The extent to which there is substitution of demand and supply in the medical services market is variable. In metropolitan areas there are sufficient numbers of general practitioners and specialists to allow consumers to make choices between suppliers of medical services. In rural and remote areas, however, the difficulty in attracting medical practitioners means that consumers are significantly constrained in their choice of provider. In addition, there is some overlap in the provision of medical services, with other health professions providing services that to a certain extent can be substituted for medical services. These include chiropractors, osteopaths, physiotherapists, and various natural therapy providers such as naturopaths and Chinese medicine practitioners. Choice of services is significantly influenced by the availability of public subsidies via the Medicare and Pharmaceutical Benefits Schemes which affect the cost of medical practitioner services vis a vis other providers. On the supply side, there are substantial constrains on substitution. Medical practitioner training is of 5 years duration with constraints on numbers of training places available. 3.2 The Objectives of the Medical Practice Act 1994 The main purposes of the Medical Practice Act 1994 are set out in section 1 of the Act. They are: a) to protect the public by providing for the registration of medical practitioners, investigations into the professional conduct and fitness to practice of registered medical practitioners; and b) to regulate the advertising of medical services; and c) to establish the Medical Practitioners Board of Victoria and the Medical Practitioners Board Fund of Victoria; and d) to repeal the Medical Practitioners Act 1970 and to make consequential amendments to other Acts; and e) to provide for other related matters. Itis clear that the key objective of the Medical Practice Act is to protect the health and safety of the community. The Board is responsible for ensuring that medical practitioners meet certain professional standards of training and practice, with details of those standards to be determined by the Board and other specialist medical colleges. Registration of medical practitioners ensures that members of the public who require medical and hospital care can be confident that the person providing that care has a recognised qualification and has achieved a certain acceptable standard of practice, including: • • • • safe practice of the various medical procedures and thorough knowledge of how to minimise risks associated with these intrusive practices; safe prescribing of pharmaceutical medications; adoption of appropriate infection control procedures; and careful monitoring of health status and referral for specialist medical care where necessary. The Medical Practice Act creates powers for the Board to: 10 • • • address patient complaints against registered medical practitioners including the conduct of investigations and hearings, and the imposition of sanctions where necessary. impose conditions, limitations or restrictions on the practice of registrants or deregister medical practitioners where necessary; and initiate action against any person who holds themselves out to the public as being registered to practice as a medical practitioner when they are not. These safeguards operate to minimise the risks of harm to the patient. 3.3 Market Failure Markets may fail to operate competitively or efficiently for a number of reasons, and these provide the principal rationale for government intervention. The need for and effects of government regulation must be assessed according to the extent to which it addresses such market failure and improves upon the outcomes of an unfettered market (National Competition Policy Guidelines for Review of Legislative Restrictions on Competition pp. 34). Market failure in the provision of medical practitioner services is of two main types: Externalities The presence of negative externalities or spillover costs arises where medical procedures result in adverse events that require the provision of additional medical services and/or hospitalisation. In many cases, these spillover costs may not be borne by the original medical practitioner who provided the service. Regulation of professional conduct by a registration board is one way in which minimum safety requirements can be imposed on practitioners. Information Asymmetry Perfect competition assumes buyers and sellers have the same knowledge about product or service quality. However, in some markets, sellers have more information about quality than buyers. This may be because it would be prohibitively costly for consumers to acquire equivalent information prior to purchase (for example where a large amount of technical knowledge is required) or because quality can only be assessed after purchase and consumption (as is the case, with most services). (National Competition Policy Guidelines for Review of Legislative Restrictions on Competition pp.38). The relationship between patients (that is, consumers) and providers of medical services is characterised by knowledge discrepancies in favour of the provider. Patients are usually not as well informed as providers and they may lack the independent ability to judge the risks of alternative treatments (including non-treatment), the efficacy of medical products and services or the proficiency of the provider. It is generally accepted that a market may fail to allocate resources efficiently when the relevant information for decision-making is distributed asymmetrically between market participants (that is consumers and providers). Therefore, government regulation may be warranted where there is a clear public interest at stake. While registration of practitioners restricts entry of suppliers to the medical services market, there is an imperative public interest justification for the registration of medical practitioners, where such registration minimises the risks to the public from inadequately trained practitioners carrying out 11 intrusive and potentially harmful therapeutic procedures. The regulatory experience in Australia and overseas is that governments have traditionally relied on professional regulation as a quality-control mechanism that restricts the practice of medicine (with its attendant health risks) to persons with recognised training and competencies. 12 4. 4.1 Legislative Restrictions on Competition in the Medical Practice Act 1994 Registration Restrictions -Background The NCP Panel identified a number of existing legislative provisions that had potential to impede competition by directly constraining consumer choice. The provisions requiring registration of practitioners are, in themselves restrictions on competition since they establish barriers to entry to the profession. The qualifications and training requirements imposed constitute restrictions on the numbers of people who may enter the market to offer medical services. If there were no statutory framework for the regulation of the medical profession, then protection of the public would rely on voluntary self-regulation by the profession and employer responsibility for the quality of services their employees provide. The Panel requested submissions on whether self-regulation is a viable alternative for the provision of medical services and what might be the impact of deregulation. If compulsory registration of medical practitioners was to be retained, then a net public benefit must be demonstrated. The key questions addressed were: • • • • What are the risks associated with the practice of medicine? What are the benefits of statutory occupational regulation? Are there alternative and less restrictive methods of protecting the public than statutory registration? Would the public be exposed to an unacceptably high level of risk if a less restrictive form of regulation was adopted? Findings and Recommendations 4.2 The NCP Panel concluded that there is a range of risks associated with the practice of medicine and that there was a net public benefit in retaining the registration requirements and restrictions on use of professional titles. In addition, statutory registration of the medical profession is the gate-keeping device that provides a basis for implementation of a range of other regulatory and funding systems, such as Medicare, the Pharmaceutical Benefits Scheme and interstate and trans-Tasman mutual recognition schemes. The alternatives for occupational regulation of any health profession include: • • • Self-regulation by the profession Legislative registration - protection of title only Legislative registration - protection of title and restriction of practice. Difficulties with self-regulation have been canvassed as part of the review of currently unregulated health occupations such as Chinese medicine practitioners, and in the context of the review of the Health Services (Conciliation and Review) Act 1989. These difficulties include: • Reliance solely on self-regulation is problematic where practices of the profession present potentially serious risks to public health and safety. These problems have been 13 documented in various government reports, specifically the Victorian Ministerial Advisory Committee report Traditional Chinese Medicine Report on Options for Regulation of Practitioners, and the NSW Joint Committee on Health Care Complaints Committee report Unregistered Health Practitioners: The Adequacy and Appropriateness of Current Mechanisms for Resolving Complaints. For example, where there are no statutory powers to restrict entry to the profession, those with minimal or no qualifications can set up practice and use the titles of the profession without meeting acceptable minimum standards of training and practice. In currently unregistered professions such as counselling and complementary and alternative therapy, this has led to widely varying standards of practice and levels of qualifications, substantial fragmentation of the professions, and no widely recognized and accepted peak professional bodies. Furthermore, under such self-regulatory systems, there have been few effective methods of enforcing compliance by training public and private institutions with educational standards determined to be acceptable by a profession. • There is potential for conflict of interest in the operation of self-regulatory schemes. Some professional associations have close links with or have been established specifically to recognise graduates of particular training institutions and provide certification only for those graduates. These links are not always transparent (Bensoussan and Myers, 1996:136-137). Complaints mechanisms can also be compromised under self-regulatory approaches. The office bearers of professional associations are generally elected by members of the association rather than appointed by an independent process. Without sufficient independent and non-profession specific input into the certification, complaints handling and disciplinary processes, there is scope for professional interests to take precedence over the public interest. In addition, associations report threats of litigation from practitioners who are requested to attend an informal hearing of a complaint. (Australian College of Acupuncturists, 1994:2). Finally, legal rights to prescribe and supply drugs and poisons that are restricted under State and Territory drugs and poisons legislation rely on a statutory registration system. A self-regulation system is unlikely to provide sufficient controls or government and consumer confidence to allow access to prescribing rights. • • The provisions of the Medical Practice Act do not restrict any of the following: • the practice of medicine by any registered or unregistered practitioner (provided they do not hold themselves out to the public as being qualified and registered or adopt certain protected titles); the number of individuals being trained in University courses; the number of individuals able to enter the profession after achieving appropriate qualifications; and the practice of aspects of medicine by other registered or unregistered occupational groups such Chinese Medicine Practitioners. • • • There was widespread industry and community support for maintenance of minimum standards via registration of medical practitioners. In summary, the Panel was of the view that self-regulation by the industry would nouidequately protect the public, because: 14 • • • • consumers have serious difficulties in determining independently, the validity of professional qualifications and/or standards of practice; there are potentially serious social and economical costs associated with provision of services by medical practitioners who are not properly qualified; a range of other regulatory systems rely on statutory registration of medical practitioners. For example, in order to claim professional titles and carry out statutory roles under the Medicare Act, the Drugs Poisons and Controlled Substances Act, and other State and Commonwealth Acts, the medical practitioner must be registered with the Board. Mutual recognition arrangements between States and Territories, along with Trans Tasman mutual recognition rely on statutory registration systems in each jurisdiction. The NCP Panel concluded that: • • there are significant risks associated with unregulated practice of medicine; there is not sufficient evidence to justify introduction of a definition of medical and additional restrictions in the Medical Practice Act on who can provide practitioner services; the least restrictive method of ensuring that the public is protected from unsafe practice is to retain the legislative restrictions on who can use certain professional practice medical medical titles. • The Panel recommended retention of the existing medical practitioner registration system based on protection of title, with an independent statutory Board made up of a majority of highly qualified members of the medical profession plus lay and legal representation. 4.2 4.2.1 Provisions to Regulate Advertising by Medical Practitioners Background The model advertising provisions were contained in the Medical Practice Act 1994. They prohibited advertising which: • • is false, misleading or deceptive; offers a discount, gift or other inducement to attract patients unless the advertisement also sets out the terms and conditions of the offer; refers to, uses or quotes from testimonials or purported testimonials; or unfavourably contrasts medical or surgical services provided by one practitioner with services provided by another. • • Penalties vary depending on whether the practitioner is an individual or part of a body corporate. The same provisions have been incorporated into the following health practitioner registration legislation: • Optometrists Registration Act 1996 • Osteopaths Registration Act 1996 • Chiropractors Registration Act 1996 15 • Podiatrists Registration Act 1997 • Physiotherapists Registration Act 1998 The NCP Panel sought comment on the standard advertising provisions as contained in the Medical Practice Act with a view to determining whether the net benefits of restricting advertising by the health professions outweighed the costs, and whether the standard provisions should be introduced in the Nurses Act 1993 and other health practitioner registration Acts. The discussion paper outlined arguments for and against powers for health practitioner registration boards to regulate advertising by their registrants. These arguments are set out below: Arguments for limiting the powers of health practitioner registration boards in relation to advertising: • Advertising is about the dissemination of information. Restrictions on advertising that exacerbate the fundamental disparities in market information can eliminate or constrain normal forms of competitive behaviour. Such restrictions can deny consumers normal forms of information about the availability, quality and price of services provided by competing practitioners, and therefore have adverse effects on efficiency, costs and prices. Consumers very rarely make complaints to the Medical Practitioners Board, for example, about advertising. Complaints received are generally from other registered medical practitioners arguably prompted by commercial rivalry rather than concern with quality of care and protection of consumers. • • The advertising provisions in the Medical Practice Act and other Acts duplicate unnecessarily, the powers of other bodies, for example: > false, misleading and deceptive advertising powers may be more effectively dealt with under State and Commonwealth trade practices and fair trading legislation. Fines of up to $50,000 can be imposed under the Fair Trading Act 1985, as compared with fines of up to $5,000 for a natural person and $10,000 for a body corporate under the Medical Practice Act. > the disparaging comments provision may be adequately covered by the law of libel and, it is argued, may act to protect professionals more than it protects the public. > abuses in advertising which refer to testimonials that are false or misleading may be covered by law of fraud and fair trading legislation. • The Medical Practitioners Board and other health practitioner registration boards have encountered difficulties in enforcing the advertising provisions due to the length of time taken to receive and investigate a complaint and then refer it to the Magistrates Court for action and the impact of the 12 month Statute of Limitations. 16 • The Medical Practitioners Board and other health practitioner registration boards have existing powers under the provisions relating to 'unprofessional conduct' to investigate and discipline practitioners whose advertising breaches the standards expected by the community and by their peers. the powers of health practitioner registration boards to Arguments for strengthening regulate advertising: • The registration boards are in many cases the most suitable bodies to discipline their members for unprofessional advertising since they are more closely involved on a day-today basis with the professions than are other regulatory bodies such the Office of Fair Trading and Business Affairs or the Australian Competition and Consumer Commission (ACCC). They may, therefore, be better equipped to identify and deal with the less serious examples of unprofessional or dishonest advertising that the ACCC and the Office of Fair Trading may not have the resources to deal with effectively, The sanctions that registration boards have available are very immediate, direct and timely. A practitioner at risk of losing his/her livelihood is most likely to take notice of Board, particularly when the Board is made up of their peers. Civil courts do not have the power to prevent a practitioner from practising his or her provision. To abandon or restrict further the powers of registration boards to regulate advertising might effectively shift the costs of such regulation from the private sector to the public sector. That is, the regulatory role of registration boards is funded via the annual registration fees levied on registered practitioners. If the Office of Fair Trading, the Health Services Commissioner or other Government funded bodies were to deal with complaints traditionally dealt with by registration boards, then there would be increased demand on public sector resources. To abandon restrictions on use of testimonials in advertising may lead to a flood of potential abuses which are likely to be very costly for a registration board to investigate and prosecute, with questionable improvements in access to information for consumers on which to make informed health care choices. • • • The Health Care Complaints Commissioner of NSW, Ms Merrilyn Walton in her submission to the NSW Parliament's Joint Committee on the Health Care Complaints Commission has commented on the difficulties that arise when the Commission refers matters to other bodies for prosecution. These include pursuing prosecutions under the NSW Fair Trading Act 1987, when medical services are treated as a commercial product. (HCCC Submission to the NSW Parliament's Joint Committee on the Health Care Complaints Commission, 28 May 1998). Ms Walton has argued that fair trading and other similar legislation is generally inaccessible to most health care consumers and accordingly is not an appropriate mechanism for maintenance of professional standards (NSW Health Department Issues Paper, Review of Medical Practice Act 1992, September 1998 pp 72). The Royal Australian College of Ophthalmologists (RACO) made a submission the Department in support of strengthening the current powers of the Medical Practitioners Board to regulate the advertising practises of registered practitioners. They argued that: 17 • the advertising powers in Victorian legislation are already the least restrictive of all Australian States and Territories, and that there are many instances of unprofessional or false and misleading advertising that the Board does not have the power to prosecute. the current regulations are in fact anti-competitive, against the public interest, and allow advertising which reduces the overall sense of medical professionalism in the eyes of many doctors and of the public. (Submission from RACO. 18 August 1997 pp.3-6). Findings and Recommendations • 4.2.2 The NCP Panel recommended amendment to the advertising provisions in the Medical Practice Act as follows: • • • Removal of the restriction on advertising that prevents practitioners from unfavourably contrasting the services of another practitioner; Inclusion of a restriction on advertising that creates an unreasonable expectation of beneficial treatment; Retention of restrictions on false and misleading advertising, offering gifts and discounts without setting out the conditions of the offer, and use of testimonials or purported testimonials. The Panel therefore recommended adoption of the following restrictions on advertising by registered medical practitioners and bodies corporate employing medical practitioners: 'A person must not advertise in a manner which: 1. is or is intended to be false, misleading or deceptive; or 2. offers a discount, gift or other inducement to attract patients to a practice unless the advertisement also sets out the terms and conditions of that offer; or 3. refers to , uses or quotes from testimonials or purported testimonials. 4. creates an unreasonable expectation of beneficial treatment; ' The Panel considered these advertising provisions to be the least restrictive provisions desirable to protect the public, in addition to those avenues of redress available through the ACCC and the Office of Fair Trading. The Panel also recommended that these provisions be introduced as standard powers for all health practitioner registration boards. False and Misleading Advertising and offering gifts and discounts without setting out terms and conditions The main provisions reflect those contained in the Trade Practices Act, and were proposed as standard provisions to be adopted in all Victorian health practitioner registration legislation. Advertising that unfavourably contrasts the services of another medical practitioner The Panel recommended repeal of this restriction on competition for the following reasons: • there was not sufficient evidence to suggest the public would be at risk if the restriction was removed; 18 • • this restriction primarily appeared to protect the profession rather than the public; and there are other avenues of redress available to those aggrieved by such advertising, in particular the laws of defamation. Use of testimonials in advertising This provision makes clear that it is an offence for a registered medical practitioner to use testimonials or purported testimonials to advertise their services. In recommending retention of this restriction on advertising, the arguments accepted by the Panel were as follows: • • • choice of medical services should be on the basis of professional competence and referral from other qualified health practitioners; testimonials are generally unsubstantiated claims made by those who may not be qualified to make such claims; testimonials may be made in response to financial incentives, and may adversely influence an individual's ability to make informed decisions concerning choice of practitioner and quality of service. Restrictions are therefore required. Power for the Board to issue Guidelines The Panel also recommended a role for the Medical Practitioners Board in issuing guidelines on what constitutes acceptable advertising by medical practitioners in order to further clarify the provisions of the legislation. This was in response to concerns raised by officers from the Departments of Treasury and Premier & Cabinet about the potential for difficulties in interpretation by courts of the generally worded provisions restricting advertising. Such guidelines may be taken into account by a court in determining whether an offence has been committed under the Act. Advertising that creates an unreasonable expectation of beneficial treatment The main arguments accepted by the Panel in favour of retaining such restrictions on advertising by registered medical practitioners are summarised as follows: • the market for medical and health services should have more stringent advertising controls than other markets, due to the information asymmetry which exists in the doctorpatient relationship, and the potential adverse consequences and cost to the community of provision of unnecessary or poor quality health care (see submissions from Victorian Health Services Commissioner and NSW Health Care Complaints Commissioner re casestudies on problems with aggressive advertising of cosmetic surgery and laser eye surgery); existing avenues for regulating advertising are not sufficient or effective enough to protect the public in this area given the risks; all submissions raised concerns about the risks to the public from the significant increase in 'entrepreneurial activities' by medical practitioners, and reinforce that the demand for and supply of medical services should not be considered the same as that of other consumer goods; precedents exist in Trade Practices law that indicate that medical advertising that is factually incorrect and/or misleading about the benefits of treatment is not necessarily found to be false, misleading or deceptive; given the potential for serious harm to patients from unnecessary medical procedures, advertising of medical services should reflect high professional standards; • • • • 19 • • • • • controls on advertising regulated by the Board are considered to reduce the risk of the public being misled by false claims to medical products and services; determination of professional standards in the interests of public health should not be frustrated by the law; further deregulation of advertising is not expected to improve access to cheaper or better quality services; the Commonwealth Therapeutic Goods Act and other State and Territory health practitioner registration Acts recognise the importance of more stringent controls on advertising in the health services market than are in place in other markets; there are strong public benefit reasons for strengthening restrictions on advertising in medical and health services and these outweigh the costs to the community from such restrictions. Net public benefit in retaining restrictions on advertising: The Panel was of the view that there is a net public benefit in retaining some restrictions on advertising regulated by the Medical Practitioners Board. The Health Services Commissioner (HSC) reported receiving multiple complaints about some medical procedures, in particular cosmetic surgery and that a common feature of these complaints was that the consumer decided to have the procedure following aggressive advertising: The use of 'advertorials' in weekend newspapers, in particular, features potentially misleading advertising. These kinds of advertisements raise expectations which are often not fulfilled and patients have been damaged physically and emotionally. Tfie performance of services like eye surgery cannot be equated with the purchasing of consumer goods. The consequences of failed procedures are extremely grave and can include blindness. The Health Complaints Commissioner in NSW has raised similar concerns, highlighting the problems of unregulated advertising in the Report of the Ministerial Committee of Inquiry into Impotency Treatment Services in NSW. The report highlighted the risk to patients from advertising by services that promoted self-referral to symptom-specific clinics. There is a growing body of evidence pointing to the need for increased controls of the activities of such clinics, including their advertising practises. The HSC acknowledges that State and Commonwealth trade practices and fair trading legislation should be able to deal with these problems. Unfortunately, these mechanisms tend to be inaccessible to most health care consumers and accordingly is not a complete mechanism for maintenance of professional standards. The HSC considers that there is a net public benefit in strengthening powers of the registration Boards to regulate advertising. Advertising of medical services is a professional standards matter and the overwhelming view of the profession should be given due consideration: There was overwhelming support for strengthening of the current restrictions on advertising, not only from the specialist medical colleges and professional associations but also from 20 community organisations and complaints bodies. These organisations urged a recognition that medical services are different from other services and that the proper exercise of professional judgements in the best interests of patients should be reflected in advertising of medical services. Justice Winneke reflects this view in his paper Appeals from disciplinary tribunals: does law or medicine set the standards? Justice Winneke stated he had: come to learn of the wisdom of leaving to senior members of a profession the task of setting and maintaining standards which are expected to be followed by the members of the profession (it is) eminently desirable that professions, through their members, should set their own professional standards. It is undesirable that, in the performance of that task, professional bodies should be frustrated by the law. Complaints about advertising are motivated by genuine concerns about risks to the public: The AMA and the Australian College of Dermatologists maintain that complaints from medical practitioners to the Board concerning advertising are not motivated by commercial rivalry. Medical practitioners make complaints about advertising because they know of the legislative requirements and are aware of the potential harm to the integrity of the profession and the doctor-patient relationship where breaches occur. Medical practitioners are also able to exercise their professional judgement about realistic expectations, whereas the public may be unable to assess the veracity of the claims that are made. Consequently, complaints lodged by doctors are usually based on a belief that the public is at risk or are being misled, rather than any commercial motivation. Further deregulation of advertising will not lead to better access or lower cost higher quality medical services: The AMA submission stated that under current arrangements: • there is vigorous price competition between GPS, with about 75% of their services bulk billed; and • patients routinely share information with their family and friends about their perceptions of the quality of care they receive. Consequently, the AMA argued that further deregulation of advertising will not improve patient access to quality general practice care, nor drive down its cost. With respect to specialist care, the huge information asymmetry between specialist and patient is well known, and cannot be corrected by less restrictive advertising. Advertising bypasses the important role of the General Practitioner: Particular concerns were raised about the risk to patients from advertising that promotes selfreferral to symptom-specific clinics. Submissions identified the key and beneficial role of the general practitioner (GP) as the gatekeeper in the Australian health care system. Advertising by such clinics has enabled entrepreneurs to encourage the public to circumvent the traditional channels of referral through the GP into the specialist system. This traditional pathway allows the provision of considered and unbiased advice by the GP, which reduces the likelihood the patient will unquestioningly accede to costly, unnecessary or ineffective treatment. 21 The AMA stated: Medical practitioners are able to exercise their professional judgement about realistic expectations, whereas the public may be unable to assess the veracity of the claims that are made. Therefore, rather than improving the information asymmetry inherent in the doctor-patient relationship, advertising that encourages direct self-referral in fact worsens the asymmetry. Concerns about the increase in 'entrepreneurial' medicine and the marketing of medicine as a commercial product; The AMA pointed to increasing concerns about advertising of medical services since deregulation. Advertising by its very nature tends to be sensational and is driven by financial imperatives. Since the current Act was proclaimed, large-scale advertising of medical services has overwhelmingly been used to promote new procedures and technologies. Often procedures do not attract Medicare rebates, presumably because the Commonwealth believes that they are unproven or only provide marginal public benefit. The Royal Australasian College of Surgeons stated: professional expertise, particularly in the surgical disciplines, should not be marketed like commercial goods or household items. The standard of surgical practice and clinical outcomes are much more likely to be less than satisfactory when the commercial aspects of practice take precedence over professionalism. The Ontario model of regulation of advertising outlined below is seen as encouraging the dissemination of information but also protecting the public. The rules permit members to communicate any factual, accurate and verifiable information that a reasonable person would consider material in the choice of a medical practitioner. Such provisions are seen as dealing with the evolving problems linked to the entrepreneurial promotion of specific services and treatments, which may prove detrimental to specific patients or the community as a whole. Other jurisdictions are increasing restrictions on advertising of medical services: At the time the review was conducted, Victoria had the least restrictive advertising provisions of any jurisdiction in Australia, and there were no indications that other States and Territories intend to further deregulate advertising. Other jurisdictions, both in Australia and overseas, have more restrictive advertising provisions than those currently in force in Victoria, and the trend is towards increasing regulation of this area. For example, in Ontario Canada, the following restrictions have been introduced in response to the increasing concerns about medical advertising: • • • • medical practitioners can advertise in any medium available to all other practitioners; the information advertised must not be false or misleading; the advertisement cannot contain testimonials, or comparative or superlative statements; medical practitioner advertising must not be associated with the advertising of products or services; No medical practitioner is permitted to: • allow his/her name to appear in any communication offering a product or service to the public; or 22 • • allow him/herself to be associated with the advertising or promotion of any product or service, other than the medical practitioner's medical service in accordance with the above principles; or participate directly or indirectly in a system in which another person steers or recommends people to a medical practitioner for professional services unless it is done honestly and with no conflict of interest. In NSW, the advertising restrictions in the Medical Practice Act include the following restrictions: a person may advertise medical services in any manner except that which is false, misleading or deceptive or creates an unjustified expectation of beneficial treatment or promotes the unnecessary or inappropriate use of medical services. Commonwealth Therapeutic Goods Act restricts advertising: The Commonwealth Therapeutic Goods Act prohibits the advertising directly to the public of substances that can only be obtained on prescription. This rule is to prevent pharmaceutical companies from making unrealistic claims to the public at large, which has no knowledge of pharmacokinetics and could be influenced by ambiguous claims of drug efficacy. It appears that the Commonwealth, not withstanding that pharmaceutical companies are bound by the advertising provisions of the Trade Practices Act, has determined that the risk to the community is too great to allow this form of direct promotion to the public. The AMA and other professional associations and specialist colleges have argued that a similar standard should apply to the advertising of medical services generally. Inadequacy of other avenues for regulating advertising of medical services: The Health Services Commissioner and specialist medical colleges have pointed to examples where the existing avenues for regulating advertising of medical practitioners are. unsatisfactory or ineffective. In particular, the Australasian College of Dermatologists included details of a matter referred to the Australian Competition and Consumer Commission that was then further referred to the Office of Fair Trading because of lack of; jurisdiction. The matter raised serious concerns and was at the time of reporting, still not resolved. Rather than unnecessary duplication of regulation, other avenues via the laws of libel and fraud are seen as more complex and expensive than parallel provisions in the Medical Practice Act. The ACCC and the Office of Fair Trading are seen as having limited resources to prosecute breaches and only those most blatant offences are acted upon. In addition, they apply a different standard to assess what constitutes 'false and misleading' advertising than that which a health practitioner registration board concerned with professional -standards might apply. For example, the AMA points to the following problems: • the Trade Practices Commission in its booklet, Advertising and Selling: A business guide to consumer protection under the TPA holds that 'puffs', the use of superlatives and comparatives, are self-evident exaggerations and are unlikely to mislead anyone; Courts have found that mere proof that behaviour has caused confusion or uncertainty in the minds of the public will not suffice to prove misleading or deceptive conduct; and an expression of an opinion will not constitute misleading or deceptive conduct if the person honestly believes what he has said. 23 • • The AMA submitted that llf sections 64 (1) (c&d) are repealed, then at the margins of medical practice, we must expect that there will be advertising that resorts to puffery and testimonials, surely the antithesis of evidence based medicine. On precedent, it is arguable that neither the Board or indeed the Courts could find such behaviour was false, misleading or deceptive, even if it was not factually correct'. While there may be only a small proportion of consumers of health services who are deceived by advertising that resorts to 'puffery and testimonials', there may be high costs associated with any adverse incidents. Unique role and position of registration boards to regulate advertising: Registration Boards, with appropriate specialist input, are considered suitable bodies to assess advertisements for medical practitioner services and to implement sanctions where necessary. The Medical Practitioners Board maintains that by virtue of its central role of protecting the public, it is able, in many cases, to persuade an errant practitioner, via peer pressure and the threat of disciplinary action, to change the offending aspects of an advertisement and thus obtain an expeditious and cost-efficient outcome. In 1997, the Board received 18 complaints, about advertising, of which only two progressed to an informal hearing, with one adverse finding of unprofessional conduct. In all instances, where a breach was found, the offending advertising was immediately corrected. The Victorian Office of Fair Trading in its submission acknowledged the overlap in jurisdiction between the Board and the Office. However, it stated that since August 1996 the Office has received only three complaints against medical practitioners, all of which were forwarded to the Medical Practitioners Board. Their submission stated 'it is acknowledged that the Medical Practitioners Board is more closely involved with the profession and would therefore appear to be better equipped to identify and deal with breaches of the Medical Practice Act'. Widespread support for retention of restrictions on advertising: The question of advertising by medical practitioners and what restrictions should be retained was thoroughly canvassed as part of the consultation process. All other health practitioner registration boards and their respective professional associations were invited to make comment on this issue, along with other interested parties and the community. Five registration boards supported retention and in most cases strengthening of the current restrictions on advertising. The AMA vigorously opposed any further weakening of the restrictions on advertising, as did the Health Services Commissioner (HSC) and the professional associations representing other registered health occupations (with the exception of the Chiropractors Association of Victoria). The strongest opposition to removing restrictions on advertising has come from the AMA and the specialist medical colleges, including: • • • • • Royal Australasian College of Surgeons Royal Australian and New Zealand College of Psychiatrists Australian College of Dermatologists (Vic) Royal Australasian College of Medical Administrators Royal Australian College of Obstetricians and Gynaecologists 24 4.3 4.3.1 Accreditation of Intern Training Positions by the Medical Practitioners Board Background Section 95 of the Medical Practice Act 1994 provided the Medical Practitioners Board of Victoria with the power to approve positions in hospitals or institutions for intern training. The Board also had the power to impose conditions, limitations or restrictions on any such approval. Part 6 Division 2 of the Medical Practice Act established the Intern Training Accreditation Committee with powers to advise the Medical Practitioners Board on intern training, receive and consider applications for approval of intern training positions in hospitals and other institutions, periodically review approved positions and make recommendations as to whether approval of positions should continue. This arrangement was designed to ensure that minimum standards are met for provision of intern training positions. The Department of Human Services provides sufficient funding each year to guarantee intern training positions for all Victorian trained medical graduates. Under these arrangements, hospitals can only offer an internship approved by the Board and their ability to create intern positions for graduates from interstate or overseas is restricted due to the costs The NCP Panel sought comment on whether there was a net public benefit in retaining restrictions on approval of intern training positions by the Medical Practitioners Board. 4.3.2 Findings and Recommendations The NCP Panel found that the Board's role in approving intern training positions did not constitute a restriction on competition for the following reasons: • • The Board's role is to approve the standard of training available to interns in approved positions, but not to determine the overall numbers of positions available. The primary restriction on the availability of intern training positions is in the form of limitation of funding made available by the Department of Human Services to pay for intern training positions. Each intem training position costs approximately $35,000 per annum. Hospitals are at liberty to find funding from within their own budgets for additional training positions and seek accreditation of these positions with the Board. In practice this does not happen, but this is due to budgetary constraints rather than restrictions imposed by the Medical Practitioners Board • The Panel did however, recommend repeal of sections of the Act that establish the role, function and membership of the Intem Training Accreditation Committee in order to facilitate the establishment of an independent Postgraduate Medical Council of Victoria with a broader role in provision of training, accreditation and education for medical practitioners in their postgraduate years 1, 2 and those in year 3 who are not enrolled in an accredited specialist college training program. 25 4.4 Powers for the Board to require Professional Indemnity Insurance 4.4.1 Background The question of compulsory professional indemnity cover was thoroughly canvassed in the Interim Report of the Commonwealth Review of Professional Indemnity Arrangements for Health Care Professionals, titled Compensation and Professional Indemnity in Health Care (the Tito Report) published in February 1994. The Final Report, published in November 1995, made the following recommendations: On balance, the Professional Indemnity Review considers that there are strong public policy reasons to support government legislation requiring all health professionals, who have the potential to cause significant harm to their patients, to have adequate professional indemnity cover as a condition of practice. (Recommendation 128) Similarly, the PIR recommends that all health care businesses, including private hospitals, day surgery facilities, pathology services and health centres which provide services to patients, that have the potential to cause significant harm, also have adequate professional indemnity cover or be required to demonstrate sufficient financial reserves to be able to meet any probable maximum loss arising from negligence in service provision. A combination of self-insurance and catastrophe cover could also be suitable, where financial reserves were sufficient. (Recommendation 129). The PIR recommends that the Commonwealth and states through AHMAC develop an agreed strategy for making professional indemnity cover (with a defined set of minimum set of characteristics) compulsory for all health professionals, either through their own cover or through adequate cover by their employer, in the case of vicarious liability (Recommendation 132J. The PIR further recommends that this strategy should aim primarily at developing nationally consistent legislation to be passed in all states, but that if this does not seem likely to occur, the Commonwealth should act within the full scope of its constitutional powers to ensure that this is a requirement for all health professionals in Australia. (Recommendation 133). In 1997, the Law Reform Committee of the Parliament of Victoria published a report titled Legal Liability of Health Service Providers. Recommendation 5 of the report stated: Statutorily recognised health service providers should be required to obtain compulsory professional indemnity insurance cover with respect to privately funded patients, in order to become and remain registered. The minimum level of cover should be specified by the appropriate registration board, in consultation with relevant professional associations. Runoff cover should be provided for those who are currently insured on a different basis to the mandatory requirement. This recommendation was implemented by the Victorian Government with the passage of the Physiotherapists Registration Act 1998. Under sections 4(2)(c), 6(3)(a), 7(2)(b), and ll(l)(b) of that Act, the Board has the power to require evidence from registrants of adequate 26 arrangements for professional indemnity insurance as a condition of initial registration and renewal of registration. Where the registrant is an employee, then a statement from their employer concerning their professional indemnity arrangements would be required by the Board. The NCP Panel sought comment on whether the Medical Practitioners Board should have the power to require evidence of satisfactory arrangements for professional indemnity insurance as a condition of registration. The Panel noted that no restrictions exist on the provision of this indemnity cover with some private insurance companies now entering the market previously dominated by a small number of medical defence organizations (MDOs). 4.4.2 Findings and Recommendations The NCP Panel accepted that the vast majority of medical practitioners, including vocationally registered general practitioners and medical specialists hold indemnity cover with one of a number of medical defence funds. Where they are employed in the hospital system, they are also covered by their employers' insurance arrangements. Insurance arrangements are required in order to be vocationally registered as a general practitioner or to take out membership of bodies such as the specialist medical colleges or the AMA. However, the Panel accepted that there are a small number of practitioners, primarily nonvocationally registered general practitioners who are not members of these bodies and may have inadequate professional indemnity or insurance cover or no cover at all. The Panel concluded that there was sufficient evidence of disadvantage to patients from uninsured doctors and the failure of less restrictive approaches to recommend adoption of powers for the Medical Practitioners Board to require evidence of satisfactory arrangements for professional indemnity insurance as a condition of registration of medical practitioners. This evidence was in the form of: • • recommendations from the Tito Interim and Final Reports and the Victorian Law Reform Commission Report on Legal Liability of Health Service Providers; submissions to the Panel from the Plaintiff Lawyers Association and various registration boards concerning cases where practitioners were found guilty of medical negligence, had failed to take out insurance cover, declared themselves bankrupt and avoided paying court ordered settlements. The Panel did not accept arguments that registration requirements for compulsory cover would be difficult to implement and administer. The Panel also recommended that these provisions be introduced as standard powers for all health practitioner registration boards. V 27 5. Summary of Costs and Benefits The costs and benefits of registration of medical practitioners are difficult to quantify. There is no unregulated market with which to make comparisons since all Australian States and Western countries appear to have similar registration schemes that control entry to and practice of the profession. In relation to the costs and benefits of compulsory professional indemnity aaangements, there is no firm data on the number of practitioners not currently protected by indemnity/insurance arrangements or the number of uninsured losses that have arisen. Such information is very difficult to access. However, in response to concerns about loss of obstetric services in rural and remote areas due to the high cost of insurance, in 1998 the Victorian Government introduced a subsidized insurance scheme for country GPs. Society places a high value on human life and does not tolerate the avoidable risk of serious injury or death from provision of unprofessional or incompetent medical services. It is considered socially unacceptable for individuals to unknowingly place themselves at risk from poor standard medical services. It is estimated that 16.6% of Australian hospital admissions resulted in an adverse event caused by health care management (Wilson et al 1995). Such a figure would be expected to increase if controls over the standard of training and practice of medical practitioners were to be removed, as would the associated costs additional medical treatment, patients' loss of income through extended hospitalisation etc. The main benefits of regulation of medical practitioner services are: • greater assurance of service quality; • improved information to facilitate informed consumer choice; • reduced risk of illness, injury or fatality; • reduction of fraudulent or opportunistic behaviour. The NCP Panel considered that: • alternative methods of regulation would not adequately protect the public, and • would in some cases breach Victoria's obligations under interstate and Trans Tasman Mutual Recognition arrangements, and • the legislative provisions were the minimum necessary to provide a satisfactory level of protection to the community, and • there was no other non-legislative way of achieving the objectives of the legislation. The costs and benefits for the key stakeholders were identified as follows: Consumers of medical practitioner services: Costs: The cost of registration and of professional indemnity insurance is passed on to consumers in the form of more expensive medical services. Registration fees are set at $300 per annum. In relation to professional indemnity insurance, most medical practitioners already have indemnity cover through one of a number of medical defence organizations or work in settings whether their employer's insurance arrangements would cover professional indemnity requirements. Therefore additional costs are unlikely. 28 There may be costs associated with restricting information to consumers through the regulation of advertising. Benefits: Access to an industry that is appropriately regulated by professionals who are qualified to determine appropriate professional conduct and impose sanctions This ensures that those who provide medical services are sufficiently well qualified to provide safe medical services & increases consumer confidence. Access to a complaints mechanism for instances of unprofessional conduct by registered medical practitioners. Practitioners who are not competent to practice can be deregistered or required to undergo further training or have conditions attached to their practice to protect the public. The standard of practice by all registered medical practitioners is maintained, with expected flow on health benefits to consumers. A finding against a medical practitioner of unprofessional conduct of a serious nature can facilitate settlement of medical negligence claims. Reassurance that persons practising medicine are appropriately qualified and have adequate professional indemnity insurance without needing to personally check their qualifications. The quality of information made available to consumers via patient testimonials and unethical advertising practices has been shown to create unnecessary demand for health services that can harm patients and cost the community in additional health services, for example in areas such as cosmetic surgery, impotence treatment and laser eye surgery. Members of the medical profession: Costs: Prospective entrants to the industry must undergo a recognised training course and be accepted for registration before providing medical practitioner services to the public. Regulation of the industry by qualified practitioners allows the adoption of appropriate standards and practices and sanction of individuals engaging in inappropriate care. Protection of professional status by: • preservation of the title; • restrictions on other statutory responsibilities which rely on statutory registration to identify suitably qualified practitioners, such as prescribing rights under the Drugs Poisons &. Controlled Substances Act. Regulation of the industry by a qualified Registration Board allows the adoption of appropriate standards and practices and sanction of individuals engaging in inappropriate care. Benefits: 29 Protection of professional status by preservation of the title rather than restrictions on practice that limit other workers within the health system is the least restrictive approach that achieves the benefits of regulation. Commonwealth Government: Costs: Benefits: None Commonwealth legislation in areas such as Medicare rely on State and Territory registration systems to identify suitably trained practitioners and regulate standards of practice. 30 6. References Australian College of Acupuncturists (ACAc) Submission for AHMAC's Regulation of Health Occupations: Acupuncture. 1994. Criteria on the Australian Institute of Health and Welfare Canberra. National Health Labour Force Series No. 16. Medical Labour Force 1998. Bensoussan, A. and Myers, S.P. Towards a Safer Choice: Chinese Medicine in Australia. November 1996. The Practice of Traditional Commonwealth Department of Human Services and Health. Review of Professional Indemnity Arrangements for Health Care Professionals. Compensation and Professional Indemnity in Health Care. An Interim Report. February 1994. Commonwealth Department of Human Services and Health. Review of Professional Indemnity Arrangements for Health Care Professionals. Compensation and Professional Indemnity in Health Care. Final Report. November 1995. Department of Human Services. Victorian Ministerial Advisory Committee. Traditional Chinese Medicine. Report on Options for Regulation of Practitioners. July 1998. Department of Human Services. Review of the Health Services (Conciliation and Review) Act 1987. Discussion Paper. September 2000. Law Reform Committee of the Parliament of Victoria. Legal Liability of Health Service Providers. May 1997. NSW Joint Committee on Health Care Complaints. Unregistered Health Practitioners: The Adequacy and Appropriateness of Current Mechanisms for Resolving Complaints. Final Report. December 1998 State Government of Victoria. National Competition Policy Guidelines. Legislative Restrictions on Competition. 1996. Review of Wilson RM, Runciman WB, Gibberd WR, Harrison BT, Newby L, Hamilton JD. The Quality in Australian Health Care Study. Medical Journal of Australia. 1995; 163(6):458471. 31 APPENDIX 1: SUMMARY OF SUBMISSIONS REVIEW OF MEDICAL PRACTICE ACT & NURSES ACT 19 January 1999 KEY CATEGORY A: CATEGORY 6: CATEGORY C: CATEGORY D: CATEGORY E: Submissions from Registration Boards, unions, professional associations, peak bodies, Specialist Colleges, educational institutions/student groups, Department. Submissions from health service provider organisations, including health care networks, hospitals, health centres etc. Submissions from nursing organisations. Submissions on specific issues: Overseas trained doctors, chiropractic advertising. Submissions from individual nurses. Key to topics: See sections of Discussion Paper titled: "Review of Nurses Act 1993 and Medical Practice Act 1994" October 1998. TABLE 1: Category A, B, C submissions, Contact persons, NCP restrictions, Victorian Model. No. A] Organisation Medical Practitioners Board Nurses Board of Victoria Chiropraclois Registration Board Optometrists Registration Board Osteopaths Registration Board Pharmacy Board of Victoria Physiotherapists Registration Board AMA Vic Branch ANF HSUA HACSU Contact Person Mr John Smith, Registrar Ms Leanne Raven, Chief Executive Mr Norman Brockley, Registrar MrJ.G.Barkla Registrar MrJ.G.Barkla Registrar Mr Stephen Marty Registrar MrJ.G-Barkla Registrar Dr E Robyn Mason Ms Belinda Morieson Secretary Mr Rob Elliott National Secretary Mr David Stephens Registration restrictions? Yes Yes Yes Yes Yes Yes Yes Yes Yes - Advertising restriction? Yes No for nurses No Yes Yes strengthen Yes strengthen Yes - Intern Training controls? Yes Yes Yes • Victorian model provisions? Yes Yes Yes Yes Yes Yes Yes pract. Protectn. - A2 A3 A4 A5 A6 A7 A8 A9 A10 All - - No. A12 A13 A14 A15 Organisation Aust Dental Association Vic. Pharmaceutical Society of Australia Aust. Podiatry Assn (Vic) Royal Australasian College of Surgeons Contact Person Mr Gerard D Condon, President Mr Roger P. James CEO Ms Gail Mulcair Executive Officer R C Bennett Executive Director for Surgical Affairs DrJohn Buchanan Hon. Secretary Dr Douglas Gin, Chair ' Victorian Faculty Chas Collison Executive Officer Ms Michelle Green Executive Director Dr Bill Newton CEO, GPD-V Ms Rhonda Nay Prof. Gerontic Nursing Registration restrictions? Yes Yes - Advertising restrictions? Yes Intern Training Controls? Yes Yes - Victorian model provisions Yes Yes strengthen Yes - A16 A17 A18 A19 A20 A21 Royal Aust &NZ College of Psychiatrists (Vic) Aust College of Dermatologists (Vic) APESMA Private Hospitals Association General Practice Divisions Victoria LaTrobe University (Nursing) Yes Yes Yes + PCAs Yes strengthen Unprof. Conduct - - - Yes Code of Conduct Yes No. A22 Organisation University of Melbourne (Nursing) Contact Person Prof. Judith Parker Head, School of Postgraduate Nursing Ms Gabrielle Koutoukidis, Nursing Coordinatory Cert. IV Ms Joan Creber, Coordinator Certificate IV in Health (Nursing) Mr Alistair Lloyd Registration restrictions? Yes Advertising restrictions? Yes Intern Training Controls? - Victorian model provisions - A23 Victoria University (Nursing) Swinbume University of Technology Yes - - - A24 Yes YesNPs - - A25 A26 Monash Uni. Med. UG Society Yes - strengthen+nurses - Yes - Yes - Ms Geraldine Buckingham, President Pre-clinicalMUMUS Mr Simon McGregor Nat. Policy Manager Ms Felicity Broughton Ms Beth Wilson Prof .Helen Baker Chair Mr Andrew Stripp, Assistant Director Mr Alan Hall, Assistant Director A27 A28 A29 A30 A31 A32 Australian Plaintiff Lawyers Association Howie & Maher Barristers & Solicitors Health Services Commissioner Pharmaceutical Health & Rational Use of Medicines Committee (PHARM) DHS - Mental Health DHS - Aged Care Yes Yes Yes Yes Yes + others strengthen false/misleading only Yes Yes - Yes - No. A33 A34 A35 A36 A37 A38 A39 A40 Organisation Royal Australasian College of Medical Administrators Royal Australian College of Obstetricns & Gynaecologists Chiropractors Assn of Vic. Pharmacy Guild of Australia National Association of Nursing Homes and Private Hospitals Inc. DHS -DisabilityServices Dept of Justice Royal Australian College of Obstetricians and Gynaecologists Contact Person Mr Stephen Krul, Registrar Mr Michael Rasmussen Chair, Vic State C'ttee Mr Norman Brockley Executive Director Registration restrictions? Yes Yes Yes Advertising restrictions? Yes AM A view No Strengthen No - Intern Training Controls? Yes Yes - Victorian model provisions Yes protect practice Yes stream- line Yes Yes Yes Mr Adrian de Jonk Mr Andrejs Zamurs FN Lovass Acting Director Mr M. Rasmussen Chairman, Victorian State Committee further review NoforPCAsetc Yes AMA view No. Bl B2 Organisation The Australian Council of Healthcare Standards Victorian Healthcare Association Ltd Aged Care Victoria Inc. Victorian Insitute of Forensic Mental Heallh Aust. College of Road Safety Freemasons Hospital Mildura Private Hospital Health Care of Australia Mayne Nickless Health Care United P/L (Private General Practices) Contact Person Dr Denis Smith Chief Executive Mr John Popper Managing Director Mr Peter Bunworth Chief Executive Ms Karlyn Chettleburgh Kerry Smith Executive Officer Ms Ros Pearson Director of Nursing Ms Trudie Chant Director of Nursing Ms Alyson Sparkes Director of Nursing Dr Henry Pinskier Registration restrictions? Yes Yes Yes Yes + PCAs Yes + PCAs Yes Yes, Div 1 And nurse practitioners Yes Advertising restrictions? Yes Yes NoforNBV Code of Conduct - Intern Training Controls? Yes Yes* - Victorian model provisions Don't know Yes* - B3 B4 B5 B6 B7 B8 - - - B9 Yes - - No. BIO Organisation Austin & Repat. Med. Centre Contact Person Division 2 Nurse Exec. Registration restrictions? Yes Advertising restrictions? Intern Training Controls? Victorian model provisions - - - Bll B12 BI3 Monash Medical Centre Southern Health Care Network Southern Health Care Network Southern Health Care Network, Mental Health Program Royal Childrens Hospital Ms Marguerite Abbott Nurse Program Director Ms Elizabeth Kennedy Corporate Counsel Ms Kim Sykes Clinical Program Director (Nursing) Dr Robert Henning Staff Specialist Intensive Care Ms Lorraine Broad Director of Nursing & Community Services Ms Valerie Zielinski Mr Rob Jane, Health Services Manager Ms Elizabeth Eadie DON & Inpatient Serv's Division 2 Nurses Yes+ others Yes +PCAs FTAct & TP Act - Yes* Yes Yes - - - - B14 B15 Bairnsdale Regional Health Service Yes retain - yes, reduce delays BI6 B17 Barwon Health The Geelong Hospital Bellarine Peninsula Community Health Service Colac Community Health Service Far East Gippsland Health & Support Service Yes + carers Yes + PCAs Yes + PCAs No Yes + nurses - Yes - B18 BI9 Yes + nurses Yes + others Yes + nurses - No. B20 B21 B22 B23 B24 B25 B26 B27 Organisation Hepburn Health Service Kerang & District Hospital Maffra Districl Hospital Western District Health Service Warburton Hospital Wimmera Health Care Group Doncaster & Templestowe Nursing Home & Day Centre Good Shepherd Aged Services Royal District Nursing Service Council of Nursing Home Directors Contact Person Ms Alice Reed Assoc. D.O.N. M.J. Kendrick D.O.N. Mrs E.J. Thomson Nursing Coordinator Ms Janet Kelsh Director of Nursing Dr John C Watts Director Med. Services Miss Wendy Lewis D.O.N. Services Ms Karen Blaszak Director of Nursing Mrs P. M. Adam CEO/DON Ms Beverley Armstrong D.O.N., Deputy CEO. Ms Mandy Christie President Registration restrictions? Yes + others Advertising restrictions? Intern Training Controls? Victorian model provisions no for nurses - - Yes Yes Yes Yes Yes Yes Yes B28 B29 Yes for nurses Yes & Div 2 - - No. B30 B31 B32 Organisation North Western Health The Alfred Dr Chris Steinfort Contact Person Mr Michael Standford Dr Michael K Walsh Chief Executive Dr Chris Steinfort Registration restrictions? Yes Yes Yes Advertising restrictions? Yes Yes Yes Intern Training Controls? Yes Yes Yes Victorian model provisions - No. Organisation Contact Person Registration restrictions? Yes Yes+ assistnt Yes + PCAs register MWs MW on Board Yes regDiv3 -1 Yes+ reg PCAs Yes +PCAs Advertising restrictions? Codes g'lines Intern Training Controls? Victorian model provisions CPE? Yes + unreg wkers Yes Nurses & MWs recogn. Mwives Yes restrict titles Yes - Cl C2 Aust. Nursing Council Royal College of Nursing Ms Marilyn Gendek EO Ms Elizabeth Percival Executive Director Mrs Philippa de Voil Chair Ms Julie Collette Hon. President Dr K. Lane Ms Jane Reilly Secretary Ms Ann Benson Victorian President Mrs Ann Turnbull President Miss Dorothy Frost President - C3 C4 C5 C6 C7 C8 C9 Ministerial Advisory Committee on Nursing Aust. College of Midwives Inc. (Vic) Maternity Coalition Aust. Council of Community Nursing Services Inc. Aust. & NZ College of Mental Health Nurses Inc. Aust. College of Nurse Management Assn of Professional Nurses Agents Inc. prof, conduct No - nurses Yes - NPs No - nurses & MPs - Yes - 10 No. Organisation Contact Person Registration restrictions? Yes Yes Yes extend scope Yes Yes Yes+ PCWs Advertising restrictions? Yes nurses Code only Intern Training Controls? - Victorian model provisions - cio Cll C12 C13 C14 CI5 C16 Victorian Perioperative Nurses' Group Enrolled Nurse Special Interest Group Melbourne (ANF) Peninsular Nurses in Aged Care Cann Valley Bush Nursing Centre Inc. Barwon Community Nurses Network Healthstra Employment Clinical Nurse Specialists Freemasons Hospital Mr Jorge AcevedoRodriguez Chairman Ms N. Birnie President Ms Robin Fuller President Ms A. Mary Filmer Mr Rob Jane, Convenor Ms Margaret Nuttall Manager Senior Nursing Staff 11 TABLE 2: Categories A, B, C, Sections 4.1.1 to 4.1.6 of Discussion Paper - Registration Board Powers and Functions No. AI A2 A3 A4 A5 A6 Organisation Medical Practitioners Board Nurses Board of Victoria Chiropractors Registration Board Optometrists Registration Board Osteopaths Registration Board Pharmacy Board of Victoria 4.1.1 Regulate Divisions training for Div 2 & amend DPCS. Medication admin training of Div 2 Agrees with Nurses Board 4.1.2 Emergencies NSW model NSW model & Olympics NSW model 4.1.3 Nurse practnrs . Yes 4.1.4 Over-seas Drs No - 4.1.5 TCM Yes Yes 4.1.6 Reg. Students Yes No Yes Yes Yes Yes A7 Physiotherapists Registration Board AMA Victorian Branch ANF HSUA HACSU Australian Dental Association (Vic) Football physios NSW model Yes - No Protect title NSW model - No No Yes No Yes - Yes Yes Yes 12 A8 A9 A10 All AI2 - uniformity NSW model No. Organisation 4.1.1 Regulate Divisions yes, review med. administration training req'd standard training training + bridging Restrict medicatn admin. amend DPCS + training train Div 2, restrict PCAs train Div 2 - 4.1.2 Emergencies Yes NSW model Mx NSW model Yes 4.1.3 Nurse practnrs will await Taskforce - 4.1.4 Over-seas Drs supports AMA view No 4.1.5 TCM MP Board set standards Yes Yes - 4.1.6 Reg. Students only overseas Drs Yes Yes Yes Yes MP Act Yes A13 Pharmaceutical Society of Australia A14 A15 A16 A17 A18 A19 A20 A21 A22 A23 A24 A25 A26 Aust. Podiatry Assn (Vic) Royal Australasian College of Surgeons Royal Aust & NZ College of Psychiatrists (Vic) Australian College of Dermatologists (Vic) APESMA Private Hospitals Association General Practice Divisions Victoria La Trobe University (Nursing) University of Melbourne (Nursing) Victoria University (Nursing) Swinburne University of Technology Mr Alistair Lloyd Monash Uni. Medical Undergrad. Society No - protect title Wait till NP Proj - Yes - similar to Midwives protect status yes prescribing rights eg optoms - Yes 13 No. A27 A28 A29 A30 A31 A32 A33 A34 A35 A36 A37 A38 Organisation Australian Plaintiff Lawyers Association Howie & Maher Barristers & Solicitors Health Services Commissioner Pharmaceutical Health & Rational Use of Medicines Committee (PHARM) DHS -Mental Health DHS -Aged Care Royal Australasian College of Medical Administrators Royal Australian College of Obstetricians & Gynaecologists Chiropractors Assn of Vic. Pharmacy Guild of Australia National Association of Nursing Homes and Private Hospitals Disbilily Services DHS 4.1.1 Regulate Divisions retain restrictions, review CRUs Div 1 supervision of med'n admin. Dosett admin OK train Div 2 & review supervisn regulate other categories 4.1.2 Emergencies 4.1.3 Nurse practnrs 4.1.4 Over-seas Drs 4.1.5 TCM 4.1.6 Reg. Students Yes, see Mental Health Act NSW model + nurses NSW model + nurses 1 Protect title endorse regn certificates Protect title later protect title wishes to contribute Yes No No review regn procedures No - Yes Yes Yes Yes+ nurses No No Yes Yes Yes - national registration. - Protect practice Train Div 2 No prescribing No extension to Div 2 regn - - - - -. 14 No. Bi B2 B3 B4 B5 B6 B7 B8 B9 BIO BI1 Organisation The Australian Council of Healthcare Standards Victorian Hospitals Association Aged Care Victoria Inc. Victorian Insitute of Forensic Mental Health Aust. College of Road Safety Freemasons Hospital Mildura Private Hospital Health Care of Australia Health Care United P/L Austin & Repatriation Medical Centre Monash Medical Centre Southern Health Care Network Southern Health Care Network Southern Health Care Network, Mental Health Program 4.1.1 Regulate Divisions Amend re med. administration Medication admin train Div 2 train Div 2 training in wkplc dereg Div. 2 train Div 2 train Div 2 same HSWs train Div 2 acute, all forms better mental health training 4.1.2 Emergencies telemedicine NSW model Yes 4,1.3 Nurse practnrs Protect title - 4.1.4 Over-seas Drs Yes - 4.1.5 TCM Yes - 4.1.6 Reg. Students Yes 'nurses - no Yes nurses - Yes - waive fees - Regulate 2 divs Yes& medication admin B12 B13 Yes - Yes - No - Yes - No - 15 No. B14 B15 B16 B17 B18 BI9 B20 B21 B22 B23 B24 B25 B26 Organisation Royal Childrens Hospital Baimsdale Regional Health Service Barwon Health The Geelong Hospital Bellarine Peninsula Community Health Service Colac Community Health Service Far East Gippsland Health & Support Service Hepburn Health Service Kerang & District Hospital Maffra District Hospital Western District Health Service Warburton Hospital Wimmera Health Care Group Doncaster & Templestowe Nursing Home & Day Centre 4.1.1 Regulate Divisions 4.1.2 Emergencies NSW model nurses & MPs Fed jurisdiction National reg. body 4.1.3 Nurse practnrs 4.1.4 Over-seas Drs 4.1.5 TCM 4.1.6 Reg. Students restrict med. admin train Div 2 articule to Div 1 train Div 2 + regulate others train Div 2 & amend DPCS UG & PG train train Div 2 not educ. prepared train Div 2 retain Regn regulate position regulate - Yes - protect public - - Yes No - Yes - 16 No. B27 B28 B29 Organisation Good Shepherd Aged Services Royal District Nursing Service Council of Nursing Home Directors 4.1.1 Regulate Divisions train Div 2 Train Div 2 - 4.1.2 Emergencies - 4.1.3 Nurse practnrs Yes - 4.1.4 Over-seas Drs - 4.1.5 TCM - 4.1.6 Reg. Students - 17 No. Cl Organisation Aust. Nursing Council 4.1.1 Regulate Divisions train Div 2 +restrict unreg. train Div 2 + amend DPCS train Div 2 + amend DPCS reg midwives separately recogn. Mwives train Div 2, reg PCWs train Div 2, protect Div3 titles train Div 2 train & reg. PCAs train Div 2 regulate others train Div 2 & amend DPCS Act retain Div 2 4.1.2 Emergencies Olympics,telemedicine—> nat.regn nat.regn NSW model Nat. Regn. Yes, nat. regn. - 4.1.3 Nurse practnrs amend legn. 4.1.4 Over-seas Drs Nat.regn 4.1.5 TCM 4.1.6 Reg. Students No - nurses Yes C2 C3 C4 C5 C6 Cl C8 C9 CIO Cll CI2 Royal College of Nursing Ministerial Advisory Committee on Nursing Aust. College of Midwives Inc. (Vic) Maternity Coalition Aust. Council of Community Nursing Services Inc. Aust. & NZ College of Mental Health Nurses Inc. Aust. College of Nurse Management Assn of Professional Nurses Agents Inc. Victorian Perioperative Nurses' Group Enrolled Nurse Special Interest Group Melbourne (ANF) Peninsular Nurses in Aged Care protect title protect title see NSW model uniform standard - No - - No - - - 18 • No. C13 C14 C15 C16 Organisation Cann Valley Bush Nursing Centre Inc. Barwon Community Nurses Network Healthstra Employment Clinical Nurse Specialists Freemasons Hospital Senior Nursing Staff 4.1.1 Regulate Divisions Extend scope practice train Div 2& regulate rest train Div 2 train Div 2 4.1.2 Emergencies 4.1.3 Nurse practnrs 4.1.4 Over-seas Drs 4.1.5 TCM 4.1.6 Reg. Students nat. registration protect title - - No - Yes Yes 19 TABLE 3: Category A, B, C Submissions, Sections 4.2.1 to 4.2.8 of Discussion Paper - Complaints and Disciplinary Functions No. Al A2 A3 A4 A5 A6 A7 A8 A9 A10 All A12 Organisation Medical Practitioners Board Nurses Board of Victoria Chiropractors Registration Board Optometrists Registration Board Osteopaths Registration Board Pharmacy Board of Victoria Physiotherapists Registration Board AMA Vic Branch ANF HSUA HACSU Aust. Dental Assn Vic. 4.2.1 Warrants Yes Yes (not applicable) (not applicable) (not applicable) qualified - 4.2.2 Legal Panel 4.2.3 Disclosure Yes Not req'd Yes Yes Yes Yes 4.2.4 Defn. unprof. Yes Not opposed Yes Yes Yes 4.2.5 Lay owners Optn4 No Yes Optn4 Yes Optn4 NZ option Yes Optn4 NZ option register agencies - 4.2.6 Suppn Order Yes Not opposed Yes Yes Yes Yes ' 4.2.7 Lapse Reg. S.40 NSW Not req'd 4.2.8 Appeals Crtof A or S.Crt VCAT OK - Yes Yes Yes Yes Yes Yes S.40 NSW S.40 NSW Yes S.40 NSW Optom exp. SCt Osteo exp.SCt VCAT, on law only VCAT S.Ct pts law only VCAT rehearing - Yes Yes Yes Yes Yes Yes qualified Yes Yes Yes define 'serious'*** - Yes Yes Yes Yes Yes Yes Yes Yes *** Yes*** 20 No. A13 A14 A15 A16 A17 A18 A19 A20 A21 A22 A23 A24 Organisation Pharmaceutical Society of Australia Aust. Podiatry Assn (Vic) Royal Australasian College of Surgeons Royal Aust & NZ College of Psychiatrists Australian College of Dermatologists (Vic) APESMA Private Hospitals Association General Practice Divisions Victoria La Trobe University (Nursing) University of Melbourne (Nursing) Victoria University (Nursing) Swinburne University of Technology 4.2.1 Warrants Yes Yes - 4.2.2 Legal Panel Yes Yes Yes Yes - 4.2.3 Disclosure cautious support Yes fairness? - 4.2.4 Defn. unprof. Yes Yes Yes, on certificate - 4.2.5 Lay owners Yes* Yes Yes Health Ins. Act Yes No - 4.2.6 Suppn Order Yes Yes Yes Yes Yes Yes 4.2.7 Lapse Reg. Yes Yes Yes Yes - 4.2.8 Appeals S.Crt expert. S.Crt 21 No. A25 A26 A27 A28 A29 A30 A31 A32 A33 A34 A35 A36 Organisation Mr Alistair Lloyd Monash Uni. Med. Undergrad. Society Australian Plaintiff Lawyers Association Howie & Maher Barristers & Solicitors Health Services Commissioner PHARM DHS - Mental Health DHS -Aged Care Royal Australasian College of Med Admins. Royal Aust. College of Obstetricns & Gynae'gist Chiropractors Association of Victoria Pharmacy Guild of Australia 4.2.1 Warrants Pharmacy Inspectors Yes Yes Yes — Yes 4.2.2 Legal Panel Yes Yes Yes Yes Yes Yes 4.2.3 Disclosure Yes Yes Yes Yes Yes 4.2.4 Defn. unprof. Yes Yes Yes Yes 4.2.5 Lay owners Yes license owners Yes register owners YesNZ option YesNZ option Option 4 Only medical owners 4.2.6 Suppn Order 4.2.7 Lapse Reg. 4.2.8 Appeals pts of law -• S.Crt quest of law only VCAT VCAT 22 Yes Yes - Yes Yes Yes - Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No. Bl B2 B3 B4 B5 B6 B7 B8 B9 BIO Bil Organisation The Australian Council of Healthcare Standards Victorian Hospitals Association Aged Care Victoria Inc. Victorian Insitute of Forensic Mental Health Aust. College of Road Safety Freemasons Hospital Mildura Private Hospital Health Care of Australia Health Care United P/L Austin & Repatriation Medical Centre Monash Medical Centre Southern Health Care Network Southern Health Care Network 4.2.1 Warrants current provisions OK Yes 4.2.2 Legal Panel Yes No objection Yes 4.2.3 Disclosure Yes Yes 4.2.4 Defn. unprof. Yes Yes Yes Yes 4.2.5 Lay owners No NoforNBV No? - current licences OK Yes register nurse agencies reg lay owners Yes 4.2.6 Suppn Order Discretionar y Yes 4.2.7 Lapse Reg. Yes No- waste of resources - 4.2.8 Appeals Unable to comment VCAT B12 - Yes - - Yes - 24 No. B13 Organisation Southern Health Care Network, Mental Health Program Royal Childrens Hospital Bairnsdale Regional Health Service Barwon Health The Geelong Hospital Bellarine Peninsula City Health Service Colac Community Health Service Far East Gippsland Health & Support Service Hepburn Health Service Kerang & District Hospital Maffra District Hospital Western District Health Service Warburton Hospital 4.2.1 Warrants - 4.2.2 Legal Panel - 4.2.3 Disclosure 4.2.4 Defn. unprof. 4.2.5 Lay owners 4.2.6 Suppn Order - 4.2.7 Lapse Reg. - 4.2.8 Appeals - - - - B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 B24 - Yes Yes - 5 yrs experience Yes - 5 yrs experience - Yes Yes - Yes Yes Yes - Yes Option 4 - Yes Yes Yes - Yes Yes 25 - - - No. B25 B26 Organisation Wimmera Health Care Group Doncaster & Templestowe Nursing Home & Day Centre . Good Shepherd Aged Services Royal District Nursing Service Council of Nursing Home Directors 4.2.1 Warrants - 4.2.2 Legal Panel - 4.2.3 Disclosure - 4.2.4 Defn. unprof. - 4.2.5 Lay owners - 4.2.6 Suppn Order - 4.2.7 Lapse Reg. Yes 4.2.8 Appeals - B27 B28 B29 _ - Yes Yes - - Yes - No NBV Cwlth legn - - - - 26 No. Cl C2 C3 C4 C5 C6 Organisation Aust. Nursing Council Royal College of Nursing Ministerial Advisory Committee on Nursing Aust. College of Midwives Inc. (Vic) Maternity Coalition Aust. Council of Community Nursing Services Inc. Aust. &NZ College of Mental Health Nurses Inc. Aust. College of Nurse Management Assn of Professional Nurses Agents Inc. Victorian Perioperative Nurses' Group Enrolled Nurse Special Interest Group Melbourne (ANF) 4.2.1 Warrants discretionary? Yes - 4.2.2 Legal Panel Yes Yes Yes Yes 5 yrs in health - 4.2.3 Disclosure Yes not req'd Yes - 4.2.4 Defn. unprof. nat. consistency Yes Yes Yes - 4.2.5 Lay owners - 4.2.6 Suppn Order - 4.2.7 Lapse Reg. - 4.2.8 Appeals • Yes Yes Option 4 No - Yes Yes Yes - Yes Yes Yes - C7 - - - - - - - C8 C9 CIO Cll status quo - Yes - status quo - - status quo register agencies - - - - - - - 27 No. C12 C13 C14 C15 C16 Organisation Peninsular Nurses in Aged Care Cann Valley Bush Nursing Centre Inc. Barwon Community Nurses Network Healthstra Employment Clinical Nurse Specialists Freemasons Hospital Senior Nursing Staff 4.2.1 Warrants - 4.2.2 Legal Panel Yes 5 yrs health exp. - 4.2.3 Disclosure Yes - 4.2.4 Defn. unprof. 4.2.5 Lay owners 4.2.6 Suppn Order Yes Yes 4.2.7 Lapse Reg. Yes - 4.2.8 Appeals - Yes - Yes 28 TABLE 4: Category A, B, C Submissions, Sections 4.3 - 4.4 of Discussion Paper: Other Registration Board Powers and Section 5 No. Al A2 Organisations Medical Practitioners Board Nurses Board of Victoria 4.3.1 Guidelns No Yes 4.3.2 PG training Yes 4.3.3Regn Renew Yes Not req'd 4.3.4 P.I.I. No Not req'd 4.3.5 Settlemts Yes - SA. Not opposed Yes Yes Yes No No Yes 4.3.6 Recency Yes 4.4 Proceds. No Not req'd NBV Recs Yes MPB Recs. 1-19 oppose 10,11,1 8 5,11,12 ,15,19. 1-12, 14-19 1-17 yes No. S34 fine • A3 A4 A5 A6 A7 A8 Chiropractors Registration Board Optometrists Registration Board Osteopaths Registration Board Pharmacy Board of Victoria Physiotherapists Registration Board AMA Vic Branch Yes Yes Yes Yes No Yr 1 only Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes 2yrs Yes No Yes Yes Yes Yes Yes Yes . Yes Yes Yes A9 A10 All A12 AI3 ANF HSUA HACSU Aust. Dental Association Vic. Pharmaceutical Society of Australia T* T* T* - No Yes Yes Yes* Yes over $20,000 No Yes Govt funded Yes Yes Uniform - 1-19 yes 29 - Yes - No. A14 A15 A16 A17 A18 A19 A20 A21 A22 A23 A24 A25 Organisations Aust. Podiatry Association (Vic) Royal Australasian College of Surgeons Royal Aust. & NZ College of Psychiatrists Australian College of Dermatologists (Vic) APESMA Private Hospitals Association General Practice Divisions Victoria La Trobe University (Nursing) University of Melbourne (Nursing) Victoria University (Nursing) Swinburne University of Technology Mr Alistair Lloyd 4.3.1 Guidelns YesMx Yes Yes nurses Yes nurses Yes 4.3.2 PG training VMPF - 4.3.3Regn Renew Verdicts only discuss more 4.3.4 P.I.I. No No 4.3.5 Settlemts No 4.3.6 Recency Yes Yes nat. study ongoing CPE employer responsib. Yes 2 yrs 4.4 Proceds. Yes NBV Recs Yes i,3,yes MPB Recs. 1-17, 19 yes 1-19 yes 234689 10,11, 121418 - MxNo Yes Yes No nurses options Yes Yes Yes Yes Yes - Yes A26 Monash University Medical Undergrad. Society - - - - - - - - 30 No. A27 A28 A29 A30 A31 Organisations Australian Plaintiff Lawyers Association Howie & Maher Barristers & Solicitors Health Services Commissioner PHARM DHS - Mental Health 4.3.1 Guidelns Yes Yes 4.3.2 PG training Yes - 4.3.3Regn Renew Yes No Verdicts 4.3.4 P.I.I. Yes 4.3.5 Settlemts No Yes 4.3.6 Recency No Yes 4.4 Proceds. NBV Recs MPB Recs. Yes Yes Yes Yes No to 9 1-7,9, 12-15, 18,19 1-7,9, 10,1215,18, 19 18 yes - Yes Yes Yes A32 DHS -Aged Care Yes Yes Yes Yes Yes + MP Yes Yes A33 A34 A35 A36 Royal Australasian College of Medical Administrators Royal Australian College of Obstetncns & Gynaecologists Chiropractors Association of Australia Pharmacy Guild of Australia Yes Yes expand ITAC retain tng length - voluntary Yes already req'd Yes No $20,000 too low - other means - - Yes Yes Yes 31 No, Bl B2 Organisations The Australian Council of Healthcare Standards Victorian Hospitals Association 4.3.1 Guidelns Yes Yes 4.3.2 PG training Interim council 4.3.3Regn Renew Condit'nal Not req'd 4.3.4 P.I.I. Yes Not req'd 4.3.5 Settlemts 4.3.6 Recency assess c'petence Yes 4.4 Proceds. Not req'd NBV Recs Yes MPB Recs. oppose 10,11,1 8 13 - yes 32 Yes Not opposed B3 B4 B5 B6 B7 B8 B9 BIO Bl 1 BI2 Aged Care Victoria Inc. Victorian Insitute of Forensic Mental Health Aust. College of Road Safety Freemasons Hospital Mildura Private Hospital Health Care of Australia Health Care United P/L Austin & Repatriation Medical Centre Monash Medical Centre Southern Health Care Network Southern Health Care Network - review nurses - - No? No Yes - both Yes - both Yes - both No Yes Yes Cont'd Ed req'mts • Yes suspens t'limit Yes - Yes Yes Yes discretion Yes - Yes Yes No. B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 B24 Organisations Southern Health Care Network, Mental Health Program Royal Childrens Hospital Bairnsdale Regional Health Service Barwon Health - Geelong Hospital Bellarine Peninsula Community Health Service Colac Community Health Service Far East Gippsland Health & Support Service Hepburn Health Service Kerang & District Hospital Maffra District Hospital Western District Health Service Warburton Hospital 4.3.1 Guidelns Yes Yes - 4.3.2 PG training 4.3.3Regn Renew 4.3.4 P.I.I. 4.3.5 Settlemts 4.3.6 Recency 4.4 Proceds. NBV Recs MPB Recs. . - Yes - No - No - Yes - qual'd Yes Yes Yes - 18&19 with care 33 Yes - private pract. - - recognise backgrnd comp'tenc not time Yes + CPE - - - - B25 Wimmera Health Care Group - - - Yes - - - - No. B26 B27 B28 B29 Organisations Doncaster & Templestowe Nursing Home & Day Centre Good Shepherd Aged Services Royal District Nursing Service Council of Nursing Home Directors 4.3.1 Guidelns 4.3.2 PG training 4.3.3Regn Renew 4.3.4 P.I.I. 4.3.5 Settlemts 4.3.6 Recency 4.4 Proceds. NBV Recs MPB Recs. - - - NoNBV Yes - - Yes + CPE assessmt - Yes No - - - 34 No. Cl C2 C3 C4 Organisations Aust. Nursing Council Royal College of Nursing Ministerial Advisory Committee on Nursing Aust. College of Midwives Inc. (Vic) Maternity Coalition Aust. Council of Community Nursing Services Inc. Aust. & NZ College of Mental Health Nurses Inc. Aust. College of Nurse Management Assn of Professional Nurses Agents Inc. Victorian Perioperative Nurses' Group Enrolled Nurse Special Interest Group Melbourne (ANF) Peninsular Nurses in Aged Care 4.3.1 Guidelns national approach Yes Yes ACMW ACMW - 4.3.2 PG training 4.3.3Regn Renew health lab.force Yes Some - 4.3.4 P.I.I. 4.3.5 Settlemts 4.3.6 Recency ongoing competnc no guarantee redefine + CPE No anomalies - 4.4 Proceds. Yes - NBV Recs Yes Yes Yes Yes 1-no Yes Yes 35 MPB Recs. - No-nurses Private practice No No split self emp - qualifying reports Yes Yes - - C5 C6 C7 C8 C9 CIO Cll C12 No. C13 C14 C15 CL6 Organisations Cann Valley Bush Nursing Centre Inc. Barwon Community Nurses Network Healthstra Employment Clinical Nurse Specialists Senior Nursing Staff, Freemasons Hospital 4.3.1 Guidelns - 4.3.2 PG training - 4.3.3Regn Renew - 4.3.4 P.I.I. split Yes MPs NPs 4.3.5 Settlemts Yes 4.3.6 Recency anomalies too vague remove Yes MPs & Nurses 4.4 Proceds. - NBV Recs 1-No - MPB Recs. - 36 TABLE 5: No. Dl D2 D3 D4 D5 D6 D7 D8 D9 D10 Dll Categories D and E - Specific Issue Submissions Name Organisation and Address Aust. Drs Trained Overseas Association Overseas trained doctor Overseas trained doctor Overseas trained doctor Derrimut Road Chiropractic Centre Chiropractor Le Lievre Chiropractic Practice Company P/L Member for Werribee Edmonds Chiropractic Clinic Chiropractor, Ocean Grove and Drysdale Chiropractic Clinics. Chiropractic Health News Issue 1 Overseas trained doctors registration Overseas trained doctors registration Overseas trained doctors registration Overseas trained doctors registration Use of testimonials in Chiropractic Health News Use of testimonials in Chiropractic Health News Use of testimonials in Chiropractic Health News Use of testimonials in Chiropractic Health News Use of testimonials in Chiropractic Health News Use of testimonials Use of testimonials in Chiropractic Health News Issue 2 Dr Eugene P Kalnin, President Dr Boris Mezhov & MrC.W.Barfoot Dr Michael Galak DrB.M.DSiddiqui Dr Gerard Christian Chiropractor Mr Brett Warden Dr Graham Le Lievre MaryGillettMP/ Dr Henry Chen Mr Richard W Edmonds Dr Nick Hodgson Mr John H. Wilson 37