The medical practitioner as the leader of the health care team

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1 AMA Queensland response to draft Ministerial Taskforce on Health Practitioner Expanded Scope of Practice report Thank you for the opportunity to respond to the draft Ministerial Taskforce on Health Practitioner Expanded Scope of Practice report. While AMA Queensland is supportive of the aims outlined in the report, the Association advocates for the implementation of changes to be cautious and measured and that the central role of the medical practitioner to diagnose patients, oversee the management of their care and lead change in the health system be maintained. AMA Queensland supports the expansion of scope of practice to full scope of practice. However, AMA Queensland does not support extension of scope of practice until full scope of practice models have been successfully implemented and evaluated. The medical practitioner as the leader of the health care team The medical practitioner s role is central to the working of the health care system in Queensland. Medical practitioners formulate diagnoses, oversee the management of patients and provide timely interventions that are necessary to maintain the health of patients. Medical practitioners have a thorough appreciation of the complexity of medical decision-making and are trained to consider the 'whole person' in developing management plans. It is imperative that the medical practitioner remains at the centre of the health care team and has ultimate responsibility for the care of the patient. Allied health professionals play an integral role in the delivery of health care in hospital settings. They have a high degree of expertise in limited specific fields and as such are able to work as part of a healthcare team in roles which have significant responsibility and limited supervision. Allied health staff play an essential role in complementing and supporting the work of doctors. AMA Queensland supports allied health professionals working at their full scope of practice, where appropriate training, supervision and advice are available. Any proposed changes to the roles performed by allied health professionals, especially extension of scope of practice, must not be introduced simply as a reaction to workforce shortages. Workforce changes must be driven by quality and safety and enhance the efficiency of the health workforce. In addition to these general comments, AMA Queensland provides the following specific comments on the draft report: Executive Summary AMA Queensland supports the key motivators of patient-focussed care, leadership at all levels of the health system, ownership of the challenge and value for money. However in regards to the leadership motivator, while it is agreed leadership is required at all levels, AMA Queensland believes reform is best achieved from the ground up, with medical practitioners and other clinicians leading the change. AMA Queensland is strongly supportive of the four principles cited in the report: patient-centred care, quality and safety, cost effective services and collaborative care many of which are included in AMA Queensland s Health Vision policy framework.

2 AMA Queensland supports the first key concept identified, that full scope of practice for allied health practitioners should be enabled, but does not support the second key concept, of extension of scope of practice, at this stage. Any proposals for change that result in better outcomes for patients and health professionals are worthy of investigation, however, AMA Queensland is concerned the model proposed for extended scope of practice in the report will have difficulty in delivering these outcomes. 2. Definitions This section provides a thorough and well-expressed overview of how scope of practice operates for health practitioners. However AMA Queensland wishes to provide the following comments with regard to the definitions provided Extended scope of practice The substitution of the role of medical practitioners with other classes of health practitioner for workforce reasons or cost saving cannot be supported by AMA Queensland. In any extended scope of practice model, AMA Queensland believes that some roles uniquely distinguish doctors from other health professionals and should only be performed by doctors 1. These include: Diagnosis and prognosis: This is a key feature of a doctor s expertise in medical practice. This is a core cognitive skill, based on both knowledge and judgement. It involves responding to the initial presentation of illness, prioritising and synthesising information, making a clinical assessment and then taking responsibility for this and following it through. Taking a patient history, physical examination and interpreting investigations requires knowledge and understanding of the full range of clinical sciences. This allows trained medical practitioners to consider the full breadth of possible diagnoses in assessing and treating a patient. Knowledge of the natural history of disease allows doctors to estimate prognosis, inform patients and their carers and underpin treatment options and choices. Complex decision-making: Doctors are required to manage complexity and risk in situations that can be characterised by uncertainty and where error can have serious consequences. The skills required for such management are achieved through training that is both intense and broad, and through rigorous certification that ensures that both knowledge and performance are tested. It is incumbent on every medical practitioner to ensure that he or she is up to date in relation to evidence-based knowledge. This continually updated skill set allows trained medical practitioners to evaluate the probability of each possible diagnosis and plan the further assessment and treatment of the individual patient. 1 AMA Position Statement: Role of the Doctor (2011). Australian Medical Association: Canberra. <

3 Training other doctors: The relationship between experienced and less experienced doctors further improves the standard of patient care. Doctors value the mentoring tradition of medical learning where senior or more experienced colleagues pass on their knowledge and skills. Doctors see it as a professional duty to mentor their newly appointed and less experienced colleagues and to be available informally as sources of advice, tutorship and support. Medical Leadership: Medical practice is characterised by taking responsibility for overall clinical outcomes. As a result, doctors are uniquely placed to take on leadership roles, including managing care and leading health services, and in the wider management and leadership of the organisations that they work in. Given the large change to the culture of Queensland Health an expanded scope of practice model is expected to produce, it is especially important that the leadership role doctors perform be acknowledged and embraced so as to help empower them to lead this change. Because of the unique role of medical practitioners, and the advanced training needed to fulfil this role, AMA Queensland does not support extending the scope of practice of allied health professionals into medical practitioner functions. AMA Queensland notes that this is acknowledged in the report, as extended scope of practice should not involve tasks considered core to a particular profession. Even if additional training and education were undertaken, AMA Queensland believes that no other class of health practitioner is, or can be, sufficiently trained in the roles of medical practitioners to meet the health needs of the community. 3.2 Delegation AMA Queensland supports appropriate delegation of tasks to other classes of health practitioner where it can be demonstrated that there is an improvement in the delivery and maintenance of quality patient care and where there is agreement between the relevant medical practitioners and other health practitioners. It is recognised some of the tasks performed by doctors may be performed safely by other health practitioners. However, for the delegation of medical tasks to be safe and effective, it must be performed in a team environment, where supervision can be provided and responsibility taken by a medical practitioner. The AMA supports the introduction of other health practitioners where these practitioners work within a healthcare team model and under the direction and supervision of medical practitioners. AMA Queensland therefore takes this opportunity to mention the importance of the role of support staff, many of whom have recently lost their jobs in the new structure of Queensland Health, in helping front line staff to deliver an effective service to patients. Even with extended scope of practice, if there is a shortage of staff, care will not improve. Consistency and planning across Queensland Health is needed if this step is to be effective in improving the health system.

4 AMA Queensland also argues that the distinction between responsibility and accountability can be more clearly articulated in this definition section. At present it is unclear how these two concepts operate together. On first reading, many of our members were concerned that, were they to delegate tasks, the delegator would remain liable for all actions of the delegate. Questions also remain about who will retain responsibility for the decision to refer patients directly to an allied health practitioner. AMA Queensland believes a medical practitioner should always be the first person to see a patient and must remain responsible for coordinating the healthcare team and managing the care of patients. However, if this is not to occur under the extended scope of practice model, clear accountabilities need to be put in place. At present, there is significant ambiguity in the draft report around delegation, accountability, responsibility and referrals, such as in sections 3.2 and AMA Queensland believes the final report needs to significantly expand its discussion on this area and should clarify the following points: Can a delegated task be refused? If not, this could affect responsibility and accountability issues for the delegate and the delegator, especially if the delegator is their direct line manager. If patients are directed to allied health professionals by a triage nurse rather than on individual doctor request, who has responsibility for the patients care? The final report must make it clear who is responsible for the initial decision to refer and what triage procedures should be put in place to handle such situations. 3. The case for expanded scope of practice for Health Practitioners 3.1 Overview of the literature Section 3.1 of the draft report acknowledges its reliance on grey literature (informally published written material) and cites just one study. AMA Queensland acknowledges professional literature on this subject is currently under development, but cannot be relied upon. In particular, the Association wishes to comment on the study which indicates that compared to doctors, suitably trained and competent allied health professionals order diagnostic tests more efficiently as an adjunct to clinical decision-making for more complex patient presentations 2. As these findings emerge from only one study, more research and assessment must be undertaken before the findings can be relied upon. In addition, the evaluation of this piece of research fails to take into account the importance of training for junior doctors, which will allow them to become highly skilled and experienced practitioners. Any potential increases in efficiency must be weighed against the 2 Nancarrow, Roots, Moran, Grace & Lyons (2013)

5 opportunity cost to the health system of reduced training capacity for medical practitioners and other health professionals, and this should be reflected in the report. In light of the paucity of cited evidence that extended scope of practice models increase efficiency or any evaluation of the impact on the training pathways for other clinicians, any programs undertaken in Queensland should be assessed regularly. AMA Queensland believes Queensland Health should commit to a publically available evaluation on each of these new programs within a reasonable timeframe (for example, 12 months from the start of the program). Progress on these reports should be reported in Queensland Health s Annual Report Patient focus AMA Queensland is strongly supportive of measures which will improve patient outcomes and experience of the healthcare system. However, AMA Queensland is concerned outcomes for patients could be compromised as a result of extended scope of practice. Whereas under the current system patients would see one doctor who would treat the patient from beginning to end, introducing one or more allied health professionals as care managers into the patients care plan could be confusing and ultimately detrimental to a patient s health care. The success of any expansion of scope of practice, as noted in the report, will rely on a number of factors, including patient load, appropriate triage processes and access to medical advice. Where patient load is not adequate, or triage is not effective, patients may find themselves passed between health practitioners as each specialist exhausts their scope of practice. Medical practitioners broad scope of practice means that their role as team leader should be preserved so as to avoid these kinds of adverse outcomes. AMA Queensland recommends that the final report significantly expand Section to discuss in greater detail what impact the proposed model will have on patient-centred care Funding models AMA Queensland is concerned that this system may end up overreaching and could end up resulting in a larger cost to the tax payer. Section of the draft report makes it clear two of the intended aims of the proposed changes are to provide value for money and greater efficiency. However, AMA Queensland is also concerned that extended may not be financially viable for the public health system. It is noted in the report that many allied health referred services are not eligible for Medicare rebates. 3 Although the report acknowledges these difficulties in Section , AMA Queensland is concerned that the proposed 3 Scope of Practice Position Statement (2009). Australian Physiotherapy Association: Melbourne. <

6 solutions, which rely on a high degree of collaboration with Medicare Locals, will be unattainable in the near future. In the final report, AMA Queensland recommends that more detailed discussion around the financial implications to the State of this model be undertaken, including how Queensland Health will ensure that these changes will provide value-for-money and any potential cost increases will be managed Education and Training of allied health professionals AMA Queensland wishes to ensure the process for deciding when to extend the scope of practice for health professionals is safe for both the practitioner and the patient. Section discusses education and training for allied health professionals. AMA Queensland supports practices which are safe, collaborative, patient-centred and promote value for money. AMA Queensland acknowledges the Allied Health Professions Office of Queensland has developed and made available a learning package to assist the workforce to develop these skills. However AMA Queensland recommends role expansion and appropriate training programs for allied health professionals should be achieved by consensus, with the involvement of doctors and allied health staff in determining the need for and type of job redesign and in the establishment of appropriate clinical guidelines. Rigorous and objective assessment processes must also be put in place to closely monitor the progress and measure the impact of role expansion on patient outcomes and team function. Accountability must be extended to individual health professionals and a culture of openness should be nurtured to solve problems and improve services. Decisions made should be clear and transparent to help drive a culture of accountability and help improve patient outcomes. Recent efforts to improve transparency in the United Kingdom by driving a culture of openness has resulted in improved efficiency, improved patient outcomes and significant cost savings. 4 AMA Queensland also recommends that this section be expanded to include discussion on ensuring allied health professionals have proper medical supervision and advice readily available, and thorough and up-to-date training is undertaken regularly. Use of tele-health services, where appropriate, should also be encouraged as a support mechanism and all health professionals should have access to appropriate administrative support services Medical workforce training opportunities AMA Queensland is concerned allied health professionals may be asked to train medical students and doctors in any new model. The public hospital system is the cornerstone of medical training in Australia and it must be adequately resourced and supported to ensure that they provide high quality healthcare as well as an optimal learning experience for trainees. However, training pathways for 4 Henke, Kelsey and Whately Transparency the most powerful driver of health care improvement? (2011). Health International. McKinsey and Company: London. <

7 medical students and doctors are already under pressure. The capacity of the medical training system is being stretched as the large increase of graduating medical students. If clinical training opportunities are reduced by the introduction of task delegation, role substitution or new classes of health practitioner, the net effect on the health of the community may be negative. The expanded nursing and allied health roles, and training for these expanded roles, must not interfere with the opportunities for medical students and doctors to learn and practice clinical skills. With the pressures the public health training system is already facing, AMA Queensland is concerned allied health professionals may be asked to train medical students and doctors in any new model. This would not be supported, as doctors work within an entirely different model to allied health professionals. AMA Queensland strongly argues the final report must address these concerns and clearly explain how medical training will be built into the new model and how it will be funded. Response to Individual Report Recommendations AMA Queensland supports most of the individual recommendations in principle with the following exceptions. Recommendation 1: This recommendation suggests the Minister for Health should lead Health and Hospital Service Boards to implement and evaluate models of care that incorporate full scope and extended scope allied health roles and tasks. AMA Queensland supports efficient care however we believe that change must come from the ground up, led by medical practitioners. Recommendation 2: AMA Queensland does not support extending scope of practice until models involving expansion to full scope of practice have been successfully implemented and evaluated. Recommendation 4: Any assessment of changes to skill mix must take into account the impact of changes on training pathways for all clinicians. Recommendation 8: The granting of accreditation status by expert accreditation bodies is the result of an independent, peer-based assessment of performance against evidence-based standards. Rather than attempting to influence accreditation bodies, an attempt should be made to work collaboratively to identify safe and effective models of care based on the available evidence.

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