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Mr Bill Prasifka, who is departing his role as CEO of the Medical Council, recounts some of the key developments at the regulator over recent years to Catherine Reilly
Professional competence has come under the spotlight during Mr Bill Prasifka’s tenure as CEO of the Medical Council. A new model is being developed and further proposals could see a ‘licence to practise’ system implemented in the future.
In late May, Mr Prasifka spoke to the Medical Independent (MI) before his departure to the US, where he is taking up the role of Executive Director of the Medical Board of California.
The New York-trained lawyer, appointed as Council CEO in October 2015, shared some of the key developments in Irish medical regulation in recent years. But a significant portion of the interview focused on the previous three months.
In response to the Covid-19 crisis and an expected surge in hospitalisations, the Medical Council embarked on an unprecedented exercise to process registration applications from retired and returning doctors.
On 18 March, the Council launched this dedicated registration pathway for doctors to re-join the register. This work was undertaken by Council staff who were also dealing with the many problems posed by the public health crisis. On 16 March, the Council had announced the sudden closure of its office in Dublin following a suspected case of Covid-19.
As of late May, around 400 doctors had been registered through the Covid-19 registration pathway.
“Obviously, in the past three months it has been very challenging here at the Medical Council during the time of Covid-19. Since really the second week of March, the office has been largely shut, except for a skeleton level of staff working on the most essential cases,” Mr Prasifka told MI.
“But during that time we have managed to establish the Covid-19 register — these are doctors coming onto the register, either coming back from retirement or coming home from abroad. The numbers are close to 400; just short of there right now.
“We have managed to put them all on [the register] on a timely basis, and that is important. We have ramped-up our remote working capabilities; upwards of 75 members of staff have full remote working capabilities — that is about three times what it was at the onset of the crisis.
“In the past month, we have had approximately 350 Zoom meetings, accumulated close to 80,000 minutes in these meetings, and have pretty much close to approaching 2,500 participants in all of these meetings. So this gives some indication that we have been successfully working remotely.
“Obviously, we are committed to the highest standards of public health and in terms of social distancing, in the months ahead, we will be reopening in line with Government policy. So we are looking at how we can actually achieve that, maintaining proper social distancing, having all the correct protocols in place, so that we are providing a safe working environment to the staff.”
Asked if it had been a costly period to date, Mr Prasifka said: “No. We are funded, 98 per cent, by the registration fees. So in terms of our income, now we are going through retention… retention numbers right now are ahead of where they were last year. But now we are at the start of that period, so we’ll keep a close eye on it.
“In terms of additional costings, well obviously, we have had to invest in remote working, so that is an additional cost. On the other hand, the office is largely shut, so in terms of opening the office, there has been a bit of a saving there. One thing we have had to do since the Government policy is have a pause of fitness to practise (FTP), because again it is very challenging to do that. In the context of remote working, social distancing, we cannot bring everybody into a room and have a hearing in the way that we did. So actually, that pause means a pause in expenditure in terms of legal fees, in terms of processing cases.
“That is not really a cost-saving because those cases have not just gone away; it is simply a delay. Now, what we are doing right now… is doing everything we can to try to ramp that up, to return to adjudicating cases to the way we had in the past. That is simply a delay of expenditure… we haven’t had the same outgoings in terms of legal fees that we would have under normal working conditions.”
More generally, the Council has been trying to develop in-house legal capacity to reduce these costs.
“That has been a work in progress for some time,” according to Mr Prasifka. “We have managed to recruit additional lawyers, we have managed to recruit additional case officers. We still have a need for outside legal advice, so that is very much a work in progress. The simple answer is that currently, we have more in-house legal resources than we have had before, but in terms of supplanting the need for outside legal advice, we have a ways to go before we make a significant dent in that.”
Returning to the Covid-19 crisis, Mr Prasifka said the Council President, Dr Rita Doyle, has throughout her term been “very strong in terms of protecting members of the public, but also supporting the profession”.
Mr Prasifka said the Council had been issuing guidance and advice for doctors and he made particular reference to the importance of continuity of care.
“These are very difficult and very challenging times. You have a significant amount of the profession really performing heroically, and so during this time we have given them guidance in terms of practice, dealing with scarce resources, how to approach practising outside their scope of practice.
“And one thing we are very strong on is ensuring there is continuity of patient care and preservation of the doctor-patient relationship, particularly in the non-Covid areas, where we have seen a decrease, for instance, in cancer screening, colonoscopies, elective surgery — all understandable, but it is very important that we ramp-up those services again, preserve the doctor-patient relationship, and we are working very hard to support doctors as they attempt to do that.”
As outlined, FTP inquiries have been paused for safety reasons and the Council is examining the means through which they can resume. Mr Prasifka confirmed there could be a remote element.
“Yes absolutely, and this is not unique to us. We have been interfacing with the Courts Service, with the Central Bank, with other regulatory agencies, so yes…there would be certain cases and matters it would be easier to do remotely.
“But the one thing we have to do without question is to ensure that the participants, that the doctors, have full procedural safeguards. So that is why we are doing a lot of studying and a lot of investment in ensuring whatever way we go forward, we can have confidence we are meeting those very high standards of procedural fairness.”
Mr Prasifka highlighted a High Court decision early in his tenure as being among the significant developments for the regulator in recent years.
“If you look at fitness to practise, the one thing that became very apparent during my time is that the High Court takes a very intensive interest in the fitness to practise cases and there were some very important decisions that came down… from the High Court early in my tenure, particularly the Enright decision.”
He said the Enright decision related to the practice of solicitors. However, it set out “some very basic principles… indicating the public had to be able to trust their solicitor and in this case, their professional, to the ends of the earth, and there had to be the highest standards of probity and honesty, and that the fundamental principle of the protection of public confidence in the profession is something that was at the very forefront of the High Court standards in reviewing our fitness to practice cases.
“In all cases where there are serious sanctions, it has to go up for confirmation before the High Court, and I would encourage anyone with an interest to go into the High Court and see how the President of the High Court deals with these cases.
“So it was very important for us as the Medical Council to embody those principles set down by the High Court in terms of how we decide individual cases… I think it would be fair comment to say there has been a progression of the Medical Council really embodying those principles in terms of deciding cases, and so that is very important, that we do that and we continue to do that. That has been an important development during my time.”
Progress is being made on evolving the professional competence scheme model, although this exercise is not yet completed. Mr Prasifka placed a particular focus on this area in the months after he took over as Council CEO.
“The professional competence schemes first came into force in 2011, so during my time here beginning in 2015, we realised, ‘Okay, the programmes have been in place now for a number of years, let’s see how we are doing’.
“And one thing which we found out was that we didn’t really have good information as to who was enrolled in schemes. So we had to improve the quality of our information and when we began to get information in, it seemed to be quite apparent that there were some registrants, some medical practitioners, who were not enrolling on the schemes on a timely basis.
“Now, I have to say, that matter has been resolved; working with the postgraduate training bodies, we have enrolment figures upwards of 98, 99 per cent, so I think that problem has been dealt with.”
While enrolment has improved, there is widespread agreement that the model of maintenance of professional competence (MPC) needs to be reformed.
In October 2017, the Council and Forum of Irish Postgraduate Medical Training Bodies organised a symposium on the “challenges and opportunities” associated with supporting doctors with MPC.
Modern clinical practice was more complex and varied, which made setting CPD at the correct level complex, it was noted. The need to use peer and practice review tools to reflect on doctors’ performance and incorporate findings to develop CPD initiatives was also highlighted. The symposium further heard that doctors should be encouraged to design a professional development plan.
Participants agreed that the current model had become “a tick-the-box compliance exercise, rather than an opportunity to engage in meaningful learning”.
These issues were outlined in the Council’s 2018 document, Maintenance of Professional Competence: Report of Progress 2011-2018.
What might change look like? According to Mr Prasifka, this is still being decided in collaboration with the postgraduate medical bodies.
However, the Council wants a greater focus on communications and reflective practice, as well as more online learning. “I would hope that by later in the year, we will be in a position to advance some changes as to how the schemes will be operating in the future.”
Mr Prasifka also confirmed the Council is investigating a ‘licence to practise’ model. This type of system applies to solicitors, for example, whereby they require registration and a licence to practise.
“As part of our strategy, we are looking at amendments to the legislation,” said Mr Prasifka. “Now, to go to such a model would require an amendment to the legislation, so let us just say, right now we are developing proposals for consideration by Council. But obviously no decision has been made at this time.”
Currently, registered doctors are legally required to enrol in a professional competence scheme and to comply with the Medical Council’s standards for the maintenance of professional competence.
Asked about the benefits of a licence to practise system, Mr Prasifka said: “It would simply make it a condition to practise that someone is up-to-date in terms of their CPD. This is the rule for solicitors, for other professions, and so that would be the reason for it, to really make CPD mandatory… Provided the CPD is relevant, accessible, actually makes doctors better, then it should improve patient outcomes. But again, that is all up for analysis and discussion, so no decision has been made.”
The initiation of clinical training site inspections has been another positive development in recent years, according to Mr Prasifka.
“In 2017, for the first time we rolled-out inspections of clinical training sites; this was part of the 2011 [legal provisions] and I think those have been quite useful. We have identified some problems, which are wider problems in the health service, [for example] lack of training time, and we continue to engage with the Hospital Groups in terms of improving site training.”
He noted that lack of protected training time has been highlighted in both the site inspections and Your Training Counts surveys.
“There has obviously been significant disruption in training in certain areas, surgery for example, during Covid-19,” added Mr Prasifka. “We are hoping that will be coming to an end and we can resume that. So it is really protected training time, I think, is the main area where we have some concern and we want to see greater resources and energy in resolving those issues.”
As to attaining entry to the specialist division, MI has learned of concerns at postgraduate medical bodies regarding the Council registering some doctors as specialists, despite a recommendation from the bodies that these doctors did not meet the requirements. These are cases where the doctors’ higher training is not automatically recognised and the route to registration is via an evaluation of existing training and experience.
Mr Prasifka confirmed there has been disagreement in some cases.
“Well, the Medical Practitioners Act is very clear; the Medical Council is the custodian of the register,” he commented. “Now, in terms of the process of granting someone specialist recognition, the application does go out to the training bodies, they make an assessment, but at the end of the day it is… a decision for Council to make on whether someone meets the required qualifications.”
It is “very difficult to generalise” in regard to these cases. “I mean, there have been cases, as you point out, where there has been a disagreement; I don’t find that terribly surprising. But certainly, any time the Council decides that someone should go on the specialist register, it is after what is a very thorough process, it is after a lot of engagement with the training bodies and with the doctor, it is after very careful consideration and I can tell you that these decisions are taking into account the totality of the doctor’s experience.
“Sometimes it may simply be the case that not every particular module in training would have been completed. Sometimes a view is taken that it is no fault of the doctor, they have had to move and not had the continuity to allow what would be the completion of all the technical requirements, but still the view is that they have the experience and the capability to act in a manner consistent with what should be expected of someone on the specialist register.”
Meanwhile, a number of cases have come before the High Court whereby registered doctors lacking in basic clinical skills have been recruited by Irish hospitals. In this context, issues around the mutual recognition of qualifications have arisen. Under an EU directive, the Council has to automatically recognise a doctor who has qualified in an EU country, where they present a qualification listed in an annex of the directive.
Mr Prasifka said these are simply the rules. He said registration does not necessarily mean a doctor is suitable for a particular role and this is for employers to determine.
“We have had these cases under EU law. If you are qualified in an EU jurisdiction you have the right to go onto the register; we don’t look behind that, and that is simply what the rules are. The only thing I can say is that it may be the case that it puts an additional burden on employers to vet particular doctors.
“Just because someone is on the register doesn’t mean they are suitable for all jobs and there is an additional burden on employers to ensure doctors are vetted, doctors are interviewed, doctors are suitable, and once they arrive they have proper induction, mentoring, supervision — that is all very important. The fundamental principle of the EU is freedom of movement and mutual recognition of professional qualifications. We don’t see that changing.”
Amendments to the Medical Practitioners Act 2007 will simplify the complaints process. When passed, all complaints will not have to proceed automatically to the preliminary proceedings committee (PPC). Instead, the CEO will be permitted to determine which complaints are sufficiently serious to go to the PPC. While some concerns have been expressed about this level of power being ascribed to the CEO, in practice, the complaints will be investigated and assessed through a case officer/s, with support from the CEO.
The Bill has been stuck in a legislative logjam and was close to enactment prior to the general election. Mr Prasifka said the Council is well prepared to implement this change.
“We have been ready to go in a world in which the Act has been amended for some time… If [the Oireachtas] had gone for an additional week, we probably may have got that over the line, so in a way that is somewhat frustrating.
“But we are ready to have a freer hand in terms of how we can manage complaints, manage them more efficiently. We are obviously trying to eliminate some of the obstacles for doctors to qualify for specialty training and it has been a source of some frustration that those amendments have not been enacted.”
Reflecting on his time at the helm, Mr Prasifka said he was “new to the healthcare area” upon entering the role and it has been a “fantastic experience”.
“It is an extremely important area, very fascinating, and I am looking forward to continuing in a different environment.
“In my experience networking with other regulatory authorities, everyone in the world is dealing with the same problems, trying to provide additional healthcare in an environment in which increasing demands are being put on the health system and that really is everywhere.
“Now, we have had incredible disruption to the whole system because of Covid-19 and that has accelerated change. Telemedicine used to be kind of a niche area; well, now it is completely mainstream, and that is absolutely essential.
“So there is lots of change happening and regulators need to protect the public foremost, support doctors, but there is a certain amount of agility there that is needed to adjust to changing circumstances.
“So that makes it a very challenging but very exciting time to be in this area. I look back on the past four years as an incredible learning experience for me. It has been very rewarding, we have seen a lot of changes happening and there is plenty to do going forward.”