Physician, heal thyself: Can AHPRA address its own complaints?

Amanda Lyons

25/11/2019 12:33:21 PM

GPs and patients have expressed concerns about how Australia’s medical professional regulator handles complaints, but the agency insists it is working towards improvement.

Doctor reading letter
AHPRA has been engaging with doctors and other medical practitioners in an effort to improve its notification and investigation process.

It’s the letter every medical practitioner dreads.
‘Your heart beats very fast when you get that letter,’ Dr Mukesh Haikerwal, doctors’ mental health advocate and former President of the Australian Medical Association Victoria, told newsGP.
Dr Haikerwal is talking about receiving a letter from the Australian Health Practitioner Regulation Agency (AHPRA) indicating you have received a notification – a complaint – about themselves.
‘When there’s a complaint, it’s a shock, it’s a bitter pill to swallow, a catastrophe,’ he said.
‘And the catastrophe is that, “If I get this wrong, my livelihood is gone, because these guys could wipe me off the [medical] register”.
‘That’s what a doctor thinks, every time they receive a letter with AHPRA on the envelope.’
But while nobody likes receiving a notification, the investigation of complaints is generally accepted as a necessary evil of a life in medicine.
‘We need an effective complaints system in Australia that can be trusted by doctors and patients,’ Dr Edwin Kruys, GP and health blogger, told newsGP.
Relatively few complaints actually result in a career limiting outcome. Notifications can be made for reasons ranging from allegations of abuse of illicit substances or sexual harassment to concerns about poor outcomes or inadequate communication.
But the investigators themselves have recently been the target of complaints, with doctors and patients railing against long delays and opacity in the process.
The recently released annual report from the National Health Practitioner Ombudsman and Privacy Commissioner (NHPOPC) revealed it had dealt with 600 complaints about AHPRA and the National Boards in 2018–19 - an increase of 45% on the previous year.
Half of the complaints (52%) focused on the handling of a specific notification about a registered health practitioner, while NHPOPC identified four common concerns regarding AHPRA and the National Boards: 

  • Delays in a decision being made
  • A lack of communication or explanation for decisions that were made
  • Concerns that not all relevant information was considered before a decision was made
  • Unfair policies and procedures 
Dr George Zaharias, the RACGP’s Senior Medical Advisor, Education Progression, understands the reasons behind such complaints.
‘From the point of view of doctors who are the subject of investigation it can be a very slow process, and both the public and doctors don’t understand the process that’s involved,’ he told newsGP.
Dr Haikerwal believes part of the reason behind practitioners’ frustration is a lack of transparency in the process and within AHPRA itself.
‘People don’t feel safe in the process because it is opaque, it is long, and it is convoluted,’ he said.
But Dr Haikerwal is optimistic due to AHPRA’s willingness to improve the situation, demonstrated in part by current engagement between the agency and medical bodies such as the RACGP.
‘I think there is some goodwill within [AHPRA] because the current CEO gets it,’ he said. ‘So I’m a bit buoyant about that.’
Dr Zaharias has a similar view, having been involved with some of this work.
‘AHPRA are very keen to work with each of the colleges to improve their processes, but also to know that doctors understand what they do,’ he said.
A delayed process
AHPRA maintains the work of the independent NHPOPC is an important part of ensuring trust and confidence in its role as a regulator with the report of increasing complaints.
Matthew Hardy, AHPRA’s National Director, Notifications, said he has heard and understood doctors’ concerns about the length of the notification and investigation process.
‘We’ve been surveying practitioners and notifiers at the conclusion of the notification process, and people are telling us some of the big issues in relation to notification management,’ he said.
‘The sense from practitioners is that the process takes a long time.’
Many doctors find the length of investigations distressing, not least because of the impact it can have on their working life.
‘Doctors may have to stop doing certain parts of their practice and have this hanging over them, whether they have actually done anything wrong or not,’ Dr Zaharias said.
‘That can have a significant impact; for example, if you’ve been told you’re not allowed to see female patients, which creates a problem that has to be managed by the practice in some way.
‘Hopefully it doesn’t look too badly on the practitioner, but one way or another patients do find out and it can hang over them for a long time.’
An ABC article from earlier this year documented allegations by AHPRA whistle-blowers that part of the issue can be traced to under-resourcing.
Mr Hardy would not comment on those allegations. He pointed to AHPRA’s efforts to improve the triaging of complaints.
‘We’re in the mindset of thorough risk analysis of notifications, and matching up their content with what we know about a practitioner and the particular type of practice they engage in,’ he said.
‘Our mission nationally is to try and reduce the proportion of notifications sent for investigation so we’re not overwhelming our investigators, but are sending things that really need to be investigated.’
Dr Kruys welcomes such moves. He was once the subject of a minor complaint he felt could have been resolved more quickly.
‘I received a complaint via a patient who thought I had made a prescribing error,’ he said.
‘Unfortunately, the patient had not contacted me but went straight to the formal complaints process. It turned out to be a simple misunderstanding but it still took a lot of time to respond, with the help of a defence lawyer, and explain that I had followed professional guidelines and there was nothing wrong with my prescription.
‘I believe that if an attempt has not been made first to remedy the issue between complainant and the health professional involved, certain complaints should not be accepted, which would avoid the system being clogged with minor, low-level issues.’
AHPRA’s Mr Hardy is of the same view that complaints are best resolved when they are initially raised.
‘Complaints can be an opportunity for practitioners to be proactive,’ he said.
‘Ensuring you have listened to the content of a complaint and taken some steps to address the concerns raised can go a long way.
‘Once it gets to us, to be able to say that remedial action is already underway is hugely positive and shows that the practitioner is being responsive to the issues that have been raised.’
Another factor that can lengthen investigation times is the involvement of other parties.
‘It could be Medicare, it could be police, it could be a drugs-and-poisons regulator in a jurisdiction,’ Mr Hardy said.
Mr Hardy noted, however, investigations that extend beyond a year are more the exception than the rule.
‘About 13% of the notifications we receive [go] beyond 12 months, and quite a few of those are because there are other proceedings underway that we need to wait for before we can conclude our investigations,’ he said.
Mr Hardy also wanted to clarify that only a small proportion of all complaints result in an investigation, and an even smaller number are a result of mandatory notifications.
‘I think people would be surprised to know that most of the notifications we get are from patients, relatives and the public,’ he said.
‘We are also closing more notifications sooner, which can only improve the experience of our processes by both notifiers and practitioners. Overall, 54% of complaints are dealt with in under three months.
‘Last year we received 14.3% more notifications yet closed 26.4% more notifications. This was alongside reducing the average time to close a matter in assessment by 14.6% and time to complete notifications overall by 5.1%.’
Don’t go it alone
Mr Hardy understands that receiving a notification can be a very isolating experience for practitioners, and one that can shake their confidence.
‘People have told us they feel alone in the process. We hear, “I thought only bad practitioners would get a notification and I didn’t think I was bad”,’ he said.
‘But there were just shy of nine and a half thousand notifications made to AHPRA last year, and 50% of them are about medical practitioners.
‘So no-one who goes through this process is alone.’
Regardless, the sense of isolation and punishment can cause practitioners considerable stress, to the point of affecting their mental health.
‘Doctors have been commenting for a long time that the complaints process is distressing, regardless of whether a doctor is at fault or not,’ Dr Kruys said.
‘The process takes a large amount of time and energy, and can obviously have reputational and professional consequences.
‘Some have argued that the stressful experience of a lengthy investigative process even negatively influences patient care.’

Dr Mukesh Haikerwal said AHPRA’s willingness to improve, demonstrated in part by current engagement between the agency and medical bodies such as the RACGP, is cause for some optimism.

Dr Haikerwal believes notifications can be expected in any medical career and are not necessarily a reflection of a practitioner’s skill.
‘When you’re graduating, you’re told you can generally expect around three reports in your career, depending on your field. If you practice in a more high-risk field, it can be even more,’ he said.
Dr Haikerwal recommends seeking support from peers to combat the stress of receiving a notification.
‘[Doctors should] talk to their friends and colleagues, their medical defence organisation, because many of them have been through it already,’ he said.
‘You have your peers, your friends, your college, other communities in health that can walk you through it.’
Dr Zaharias emphasises the need for doctors to access quality professional advice and practise self-care during an AHPRA investigation.
‘Generally, doctors will get the assistance of their medical defence organisation, who will help them with any legal processes,’ he said.
‘And then it’s really a matter of seeing your own doctor, getting access to counselling and support that way.’
AHPRA is also keen to help reduce doctors’ sense of isolation. It has made efforts to provide more detailed information in notification letters about what the process involves, as well as additional resources on its website, including videos featuring practitioners who have been through such a situation themselves.
‘The message is, don’t try and go through this alone, because your questions can often be answered very simply if you just go out and get help,’ Mr Hardy said.
‘That help can be from other colleagues, it can be from your [professional indemnity insurance] provider, it can be from the resources on the website. But it can also be from AHPRA itself.
‘People tell us that speaking to the case officer who’s assigned to the case is a really good thing to do, because we can reassure them that the notification is not necessarily career-limiting and is usually about getting a response on the record that isn’t a lawyers-at-10-paces-type response, but a genuinely reflective-type response.’
Dr Haikerwal had some advice for such a reflective response, advising it is often helpful as to acknowledge a complainant’s experience.
‘It’s important to be able to talk with people,’ he said. ‘“Sorry” doesn’t necessarily mean you are admitting guilt. It means you’re sorry something bad happened to someone, or that something bad was said to someone.
‘It’s to do with how you undo the harm that was perceived, if not actually caused.’
Assessment by other health professionals
A common complaint among practitioners who have been through the investigation process is the sense their case is being assessed by ‘faceless bureaucrats’ – people without medical knowledge or empathy for the experience of being reported as a doctor.
When asked what he would like to see from the process, Dr Kruys was clear.
‘Rapid assessment by an experienced, skilled assessor who has in-depth knowledge of the specialty the doctor works in, stays on the case from beginning to end, and regularly informs the doctor about progress made,’ he said.
‘And, as the majority of cases do not result in regulatory action, a supportive, non-judgmental approach is key.’
Mr Hardy acknowledges these complaints from doctors and said AHPRA has taken them on board in its efforts to improve.
‘We’ve beefed up the number of medical practitioners we employ so now every medical notification, is looked at by a clinical advisor – that’s relatively new,’ he said.
‘But what’s not new is that the people who make decisions about every notification are the National Boards.
‘So those state and territory boards and committees appointed by health ministers are still the ones making decisions about what should happen with the notification, from the time it comes into the system until the time that they’re satisfied it can exit the system.
‘Each of those boards and committees are made up of 70% medical practitioners, 30% community members, on average. So there are medical practitioners involved from day one, and certainly involved in all the decision-making.’
On the whole, Dr Zaharias is optimistic that positive changes are being made. He is hopeful things will improve even further in the future, as AHPRA listens to input from the RACGP and other medical bodies.
‘I think they are hearing the complaints and are actually starting to make changes,’ he said.
‘But change, of course, doesn’t happen suddenly. It takes time in itself.’

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Dr Peter James Strickland   26/11/2019 12:24:41 PM

AHPRA have several big problems. They were set up originally to allow Australia-wide registration of practitioners, but the move has failed. They are an expensive, inefficient and a bureaucratic authority now, and like one monstrous education department in Australia trying to control local disciplinary problems etc. in schools. The solution is easy; dissolve AHPRA, and bring all registration and disciplinary problems back to the States ---- it will be cheaper, far more efficient and informed on local problems, quicker at giving justice, and much less controversial to all concerned. AHPRA should be made redundant, as the organization appears to have reached its end of usefulness to anyone, and especially to practising doctors and patients of Australia.

Dr Graham James Lovell   30/11/2019 7:46:06 AM

I feel quite the opposite.
I have seen a state based Medical board successfully prosecute a Specialist, and then let his General Practitioner wife supervise his hospital admissions ,despite the written concerns of the hospital .
I have similarly in the past mandatory reported on a repeat offending narcotic abusing General Practitioner,only to find out their supervisor was working in the country .
Patients with concerns about their doctor’s surgical results are currently being flown interstate for Medicolegal opinions.
So I would prefer to see improvement of the until now seriously flawed AHPRA,from whom I have in writing a letter stating that it is NOT in the public interest to understand the workings of their decisions.
Why?-because at least this key issue of transparency is out in the open,where hopefully like ‘Pandora’s box’ it can’t be put back away.