National registration scheme at 5 years: not what it promised.

A national registration scheme for health professionals was introduced in Australia 5 years ago, replacing the long-standing state-based schemes. This review examines whether the scheme has delivered what it promised and makes recommendations for change. The available evidence indicates that the scheme's design and its implementation were rushed and that the legislation has serious flaws. Two parliamentary inquiries and the experience of registrants confirm that the system is more expensive, remote and bureaucratic than the previous state-based systems. The scheme has delivered benefits only in relation to portability of registration and a single national register. In addition, with two large jurisdictions participating in a 'co-regulated' mode, it is not truly a national scheme. To restore the confidence that health professionals need to have in the regulator, it is recommended that all jurisdictions seek to be 'co-regulated' and that the Australian Health Practitioners Registration Authority be pared back to providing a central database for national portable registration.

Revalidation - what is the problem and what are the possible solutions?

The proposed introduction of a revalidation process as part of renewal of medical registration in Australia needs wide debate. The revalidation process that began in the United Kingdom in 2012 is premised on a need to regain the trust of the community and to promote participation in continuing professional development. These alone are not justifiable grounds for introducing a similar process in Australia. There are good reasons to argue that existing processes and databases should be used to determine more accurately what the weaknesses in Australia's medical regulatory regime are and to tailor improvements to those weaknesses.

A no-fault compensation system for medical injury is long overdue.

The 2011 report of the Productivity Commission (PC) recommended the establishment of a no-fault national injury insurance scheme limited to "catastrophic" injury, including medical injury. The report is welcome, but represents a missed opportunity to establish simultaneously a much-needed no-fault scheme for all medical injuries. The existing indemnity scheme based on negligence remains a slow, costly, inefficient, ill targeted and stress-creating system. A fault-based negligence scheme cannot deter non-intentional errors and does little to identify or prevent systems failures. In addition, it discourages reporting, and thus is antithetical to the modern focus on universal patient safety. A no-fault scheme has the potential to be fairer, quicker and no more costly, and to contribute to patient safety. No-fault schemes have been in place in at least six developed countries for many years. This extensive experience in comparable countries should be examined to assist Australia to design an effective, comprehensive system. Before implementing the recommendations of the PC, the federal government should ask the Commission to study and promptly report on an ancillary no-fault scheme that covers all medical injury.

Doctors' health: can we do better under national registration?

The move to national registration of doctors presents both threats and opportunities for the manner in which doctors seek health care and for providing assistance to doctors who may be impaired by illness. The most striking threat is the regressive nature of the provisions for mandatory reporting of ill doctors. The new system should be grasped as an opportunity to achieve national agreement on resourcing adequate services to help distressed doctors and to foster education and research into the health of doctors and medical students. The new system also provides opportunities to explore ways of encouraging doctors to improve their poor record of not attending to their own health, such as denying Medicare rebates for most doctors who self-refer.

Gastroesophageal reflux and related pathology in adults who were born with esophageal atresia: a long-term follow-up study.

BACKGROUND & AIMS: Esophageal atresia (EA) is the most common congenital anomaly of the esophagus. There are few long-term follow-up data on adults who had surgery for EA as infants. The primary aims were to evaluate the prevalence of esophageal symptoms and pathology and second to develop recommendations for follow-up. METHODS: This is a descriptive study of individuals attending a clinic in an adult tertiary referral hospital, established to provide care for adults who had surgery for EA as infants. Individuals aged 20 years or older were identified from an existing database and invited by telephone to attend the clinic. One hundred thirty-two patients attended the clinic from 2000-2003. Individuals were assessed by using a structured questionnaire. Endoscopy was performed in 62 patients because of symptoms. RESULTS: Reflux symptoms were reported by 83 (63%), including 25 (19%) with severe symptoms. Dysphagia was reported by 68 patients (52%). Of those who underwent endoscopy, reflux esophagitis was present in 36 patients (58%), Barrett's esophagus in 7 (11%), and strictures in 26 (42%) patients. One patient was diagnosed with esophageal squamous cell carcinoma. Men who were 35 years or older and individuals with severe reflux symptoms were at high risk of having severe esophagitis or Barrett's metaplasia. CONCLUSIONS: Reflux symptoms, esophagitis, and Barrett's esophagus are common in these individuals. We recommend clinical assessment as adults and upper endoscopy for reflux symptoms or dysphagia. Transition of young adults from pediatric care to an adult gastroenterology clinic with expertise in EA appears to be highly beneficial.

Improving Australia's ethical review processes--slow and steady wins the race.

In this response, the Australian Health Ethics Committee (AHEC) indicates that it shares, and has strategies in place to address, the majority of the concerns identified by Susan Dodds. AHEC believes it is too early to assess the full impact of the National Statement on Ethical Conduct in Research Involving Humans (1999) or to call for a major review of the ethics committee process. While some Human Research Ethics Committees (HRECs) are overstretched, the system is not on the verge of collapse.

National registration legislative proposals need more work and more time.

The release for public consultation of the draft Health Practitioner Regulation National Law 2009 represents a once-in-a-generation opportunity to ensure best practice in medical regulation. The draft law fails to build on the best aspects of existing state and territory legislation, particularly in regard to how allegations of misconduct, poor performance or impairment are to be handled. If adopted, this legislation has the potential to set back important improvements to professional regulation that have been implemented in Australia in the past 20 years. There are also legitimate concerns about mandatory reporting provisions and the likely increased cost of regulation. More time and more work are needed to get this new scheme right.

Medical professionalism: is it really under threat?

Recent publications on medical professionalism have created an impression of a medical profession under siege in several countries. These publications recommend a new approach to medical professionalism to assist the profession to respond to new challenges. I suggest that the issue is not one of failed professionalism, but a shift in the balance of the ethical responsibilities brought about by major changes in health care systems. This shift has not yet been accepted or responded to by the medical profession. Medical professionalism is not under threat in Australia. Stronger leadership is required to address this altered ethical balance in the responsibilities of doctors.

Strengthening Australia's framework for research oversight.

All stakeholders should contribute to enhancing Australia's guidelines for ethical research.

Improving the governance of health research.

Australia has so far been spared serious mishaps in health research, but rising pressures on researchers, deemed to have contributed to two deaths of research participants in the United States, clearly also exist in Australia. Health research investment in our institutions is large and represents an often overlooked area of risk by boards of management. Research governance (the framework through which institutions are ultimately accountable for the scientific quality, ethical acceptability and safety of research conducted in the institutions) has not received sufficient attention. An adequate governance framework requires institutions to have policies and procedures in place to meet national ethical, legal and research practice standards. We suggest that many institutions presently do not have such frameworks in place and inappropriately rely too heavily on human research ethics committees. To ensure ongoing adequate protection of research participants, we recommend some simple improvements for research governance and suggest ways by which institutions can demonstrate adherence to agreed national standards.

The medical profession and the pharmaceutical industry: when will we open our eyes?

There is evidence that drug-marketing techniques affect doctors' prescribing practices. This has ethical implications for doctors, as it affects the trust required in the doctor-patient relationship. Doctors need to recognise they are affected by drug marketing, and take steps to maintain their independence from the pharmaceutical industry.