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Taking the helm at Kingram House

Mr Bill Prasifka has a strong message for doctors: ensure your CPD is done. Around 30 per cent of doctors are not fulfilling their legal obligation of maintaining professional competence, the new CEO of the Medical Council has said in an interview with the Medical Independent (MI).

Mr Prasifka acknowledged that “many do” meet requirements, but the scale of the problem is perturbing the US-trained lawyer, who took up post in October. It has been the strategic focus of Mr Prasifka’s early public pronouncements. “This is an issue and this is a problem,” he informed MI

Since May 2011, doctors are legally required to enrol in Council-recognised professional competence schemes, unless in a training post. The requirement entails 50 hours of CPD and one clinical audit per year and the schemes are run by the postgraduate training bodies.

The Council has a legal duty to be satisfied as to the ongoing maintenance of doctors’ professional competence. Mr Prasifka posited the prospect of instigating annual doctor licencing, if the situation cannot be resolved under the current framework.

 “We obviously don’t have any master set of information, knowing which doctors are taking which courses… ” Mr Prasifka explained. “But from our sort of overall intelligence, it would appear that depending on the class or category of the doctor, around 30 per cent are not meeting their professional education requirements that they are required to do under the Act.” The issue mostly pertains to doctors in the general division, he added.

A “co-ordinated response” is required from stakeholders including the Council, employers and indemnifiers, according to Mr Prasifka. He said some doctors had been brought to fitness to practise (FTP) proceedings and issued with fines, and this will continue.

However, there is “no future” in the prospect of thousands of doctors passaging through FTP proceedings, he conceded.

“And really, we’d like the profession to take a very strong message that continuing professional development is something they have to take very seriously. Many of them do. Particularly for those doctors on the specialist register, we find their uptake is higher — much higher — than it is for others. So again, it is not a problem throughout all elements of the profession, as far as we can tell…

“My concern would be that this may be some indication of very poor morale within the system — that there are some doctors who have very poor morale, who are stressed out, who are not getting proper mentoring, proper supervision. That’s just a theory but it’s one that really concerns me.”

Mr Prasifka said that, in some professions, a licence to practise was dependent on undertaking CPD. He considers this a viable prospect.

“For example, if you are a solicitor and you haven’t done your CPD, you don’t get your practising cert. There are two tracks: there is initial registration, and then there is an annual licencing. Now, that is the way other professions deal with those kinds of issues. We don’t have that here.

“But I could see, if this problem is not rectified, that would have to be one approach that should be given very substantial consideration. Because look, if you are an airline pilot, you have to spend so many hours on the simulator or else you will not be flying. It is not unreasonable to look for a similar type of system in terms of our registering medical professionals.”

Ultimately, if the problem cannot be addressed under the current framework, “it would be my job and it would be a public imperative that we advocate changing the framework”.

Should any doctors feel that CPD provision could be improved, “we are all ears”. But opting out is not an option, he maintained.

As part of the process for the annual retention of registration, doctors make a declaration regarding maintenance of professional competence.

The Council then contacts a sample of doctors to participate in an audit of their activities.

According to the Council’s 2014 annual report, it made complaints against 13 doctors who, despite renewing registration with the Council for 2014/2015, had not responded to the audit requirements. In 2014, the Preliminary Proceedings Committee (PPC) referred six doctors to a professional competence scheme, in comparison with five in 2013. In 2014, there were 26 complaints against doctors regarding maintaining competence, as against one in 2013.

Competition body

Mr Prasifka took over as Council CEO last year, following the departure of Ms Caroline Spillane. Originally from Los Angeles, he trained as a lawyer in New York. His wife is Irish and he will have lived in Ireland for 28 years this summer.

He will be known to many doctors, particularly GPs, as having been Chairperson of the Competition Authority (now the Competition and Consumer Protection Commission) in the mid-to-late 2000s. 

Over the years, the competition body and IMO have butted heads on issues affecting GP members.

Asked if he was apprehensive taking up his Council post arising from this history, he told MI: “No, not at all. Absolutely not.” He said he is “very proud of the work we did there”.

“One of the great virtues of competition policy is you have the same policy for everybody, whether you are running a pub or whether you are a doctor, or whether you are running a telecommunications system, or an airline, or whatever it is, it is the same set of rules. And I certainly believe that we are all better off if we follow the same rules.”

So I certainly accept the fact that the salaries [in the public sector] were reduced and if you don’t like it, well, you can do something else, is the way I would look at it

Until early 2015, Mr Prasifka was the Financial Services Ombudsman. He is also a former Commissioner of Aviation Regulation. His background in complaints management and regulation means he brings plenty of relevant experience to Kingram House.

This experience has been “quite useful” but healthcare regulation is a new area for Mr Prasifka. It has been an “exhilarating” change, offering opportunities to meet new people and take on new challenges.

Between 2012 and 2014, the Medical Council CEO salary dropped from €145,952 to €136,276 under the terms of the Haddington Road Agreement. Ms Spillane, who was CEO from October 2010, departed last year on the €136,276 salary, but Mr Prasifka took up the post on €115,576. Mr Prasifka is on the PO Higher Scale at the last point (long service, increment 2) plus a Director’s allowance. The Department of Health refers to this as a Director’s salary, according to information recently released by the Council following a Freedom of Information request (the Council also publishes the CEO salary in its annual reports). 

Did Mr Prasifka consider that the previous salary was too much?

“Well look, I have been in the public sector for some time… Simply, the country was effectively put into receivership and so things had to happen. So I certainly accept the fact that the salaries were reduced and if you don’t like it, well you can do something else, is the way I would look at it.”

To his knowledge, the CEO salary will remain “there or thereabouts. I mean, I don’t have any information that the salary is changing up or down.”

Many doctors keep an avid eye on Council expenditure. After all, the regulator is funded through doctors’ registration fees.

Last summer, there was a bitter dispute between doctors and the Council on the registration fee hike to €605 from €535, a rise the Council linked with its growing remit and restrictions on diversifying income.  The IMO did not secure a reversal of the fee increase, despite its campaign against the rise, but the Council agreed to talks on fee structure and issues such as ability to pay.

Mr Prasifka said these matters are presently “with Council”, which will indicate the way forward, “and I assume that would happen relatively soon”.

He acknowledged that there are resource issues in some sections of the Council: “But overall, if you look at the resources of the Council, and particularly if you compare us to some of the other health regulators, I think it’s no secret that some of the other health regulators have significant resource issues. But we are in a different category — not that we have enough resources to do everything we possibly imagine, but we have significant resources to do a significant amount of what we want.”

Nevertheless, the Council wants to diversity its income and this requires legislative change, he noted.

‘Outdated structure’

Mr Prasifka takes the helm at a time of significant change on the horizon, especially in the context of anticipated amendments to the Medical Practitioners Act, 2007.

There are numerous important changes proposed to the legislation. Mr Prasifka appeared reluctant to discuss individual points in detail, but, as previously revealed by MI, that one of the proposals is that doctors in FTP proceedings would no longer be automatically named.

Yet perhaps the most crucial change will be greater means of circumventing the FTP apparatus, if deemed appropriate. This would allow for early-stage mediation and acceptance of undertakings, obviating the need to go to full hearing.

Nevertheless, there would be certain cases “which really can only be resolved at a full hearing”.

The current structure is “very rigid” and “outdated” when one looks at comparable regulatory bodies. “We certainly don’t have any pushback on those [suggestions] from the Department of Health but we fully understand that any kind of change like this requires time. But we are hopeful we can see this through before the end of the year.”

The one thing I find inexplicable is as to why almost all of
the media attention on fitness to practise is with the Medical Council

The Corbally ruling is another exercising matter. Legal experts have stated that there is now no material difference between professional misconduct and poor professional performance. Will proposed legislative change include another dimension of finding?

“Well look, those are all with the Department of Health. But where we are today is, we are very much working within the Corbally decision. That is the only thing that we can do and that is what is most appropriate for us.”

Media coverage

Mr Prasifka is puzzled by the extent of media coverage of Council inquiries, in comparison to other regulatory proceedings with human interest dimensions.

“The one thing I find inexplicable is as to why almost all of the media attention on fitness to practise is with the Medical Council. I mean, there are other professional bodies who have similar types of systems — whether it’s the solicitors or the accountants — and why is it that we get all the coverage, rather than they do? And I must say, I don’t have an answer to that.

“I am not saying doctors are unimportant. But for example, say you were someone who lost your life savings because of some action by an accountant, or some very important legal matter destroyed your life, because of a lawyer, there has to be the case that there are issues with these other bodies that have compelling personal interest dimensions to it, but for whatever reason the media do seem to focus on us.

“Now look, we just have to get on and do our jobs, and the media has every right to cover what we do. And what we try to do, as I hope you understand, is to facilitate that as much as we possibly can. But I just note that there isn’t the same level of interest in these other bodies.”

Bullying

At the same time, significant media attention has centred on recent Council research on trainee experiences, as part of its Your Training Counts annual report series.

According to the 2014 report, bullying and undermining behaviours were “endemic” in the clinical learning environment, based on trainee-reported experience. Approximately three-in-10 trainees reported personal experience of bullying and undermining behaviour, and this experience was over two times more prevalent than for their UK counterparts.

The 2015 report offered similarly stark findings. The Council has been working “very closely” with the postgraduate training bodies on the issue, said Mr Prasifka.

“As you know, we have accreditation visits of the postgraduate training bodies, and of clinical sites, and the information from Your Training Counts can inform us of how we go about that process. We can go in there looking for what have been the incidences of bullying and, more importantly, if we are looking for a structured response, how are the bodies dealing with it, what programmes are they putting in place? 

“The one thing that has been encouraging is that many of these training bodies relatively recently, within the past year, have come up with substantive responses —they have put in place bullying hotlines, mentoring programmes, have worked more closely with their trainers to ensure they are acting properly, and really have attempted to come to grips with the problem.”

Bill Prasifka on….

New induction programme, Safe Start

The Council is developing an “educational intervention” called Safe Start for doctors new to medical practice in Ireland. It has not been decided if it will be tied to registration, said Mr Prasifka.

“We have commissioned research from UCD to help us formulate the programme and we’d be looking to roll that out in 2017.”

Through the complaints process and surveys, the Council has identified that there can be difficulties in respect of doctors beginning practice in Ireland. These issues often relate to ‘softer skills’, including communication and understanding the system.

 “But obviously there is no point in having such a programme unless people are doing it. So we are going to have to think of strategies and how exactly we are going to do that.”

Safe Start will be “no substitute” for proper induction, training and mentoring.

One-on-one meetings with staff

According to minutes of Council meetings, Mr Prasifka embarked on one-on-one meetings with every staff member after taking up post. The regulator has approximately 65 employees.

“This was a practice I had started in a previous job, where I met individually with each member of staff,” Mr Prasifka told MI. “It was very important to find out what they were doing, to find out what they would like to do, to find out how they could develop within the organisation. I think it is very useful for an organisation for people to think they have a future within the broader organisation, so they can move to one section from another.

“And also for me, as someone coming new to the organisation, it was a very good way for me to get to know the organisation, by talking to each member of staff.”

He generally found Council staff to be “extremely good, to be very energetic, to have a strong sense of the public ethos here”.

New ethical guide

The Council is expected to launch a new ethical guide in May, which will update the 2009 version.

 “It will be one of the most important pieces of work we will be releasing this year, arguably the most important work. There will be a launch, and then after the launch, there will be a series of other projects of interactive guides and additional material…

“I am not giving away any secrets to say it is not a complete transformation of other ethical guides. I mean, the ethical guides remain fairly constant, but they need to be consistently updated, and obviously, for example, there would be certain new ways of delivering medicine that probably didn’t exist a couple of years ago. The goal is to both facilitate new entry while ensuring the new entry doesn’t compromise any ethical standards. Those are the challenges we face.”

He said it is clear that online services are a very attractive option to many patients, which must be taken into account.

“But on the other hand, it does raise certain questions, and we have to make sure that the same standards of clinical robustness are preserved, and so those are the overall goals.”

The Council’s premises

The Medical Council recently put its former headquarters, Lynn House, Rathmines, on the market. It is seeking €2.75 million for the four-storey office building.

“Lynn House is currently vacant. It previously was the premises of the Council,” said Mr Prasifka. “I think it was rented out for some period of time; I understand those tenants have left. Certainly the Council came to the conclusion that Lynn House was no longer needed for any Council use, and so the obvious thing was to sell it. We are in the process of doing that.”

Controversially, the Council entered into an arrangement in 2008 whereby it was tied into a 20-year lease on Kingram House with an annual rent of €820,000. The market rent for the property is reportedly less than half of this. The lease will expire on 31 December 2032.

The terms were subject to litigation and the judgement found in favour of the building’s owners. The Council appealed this decision, but subsequently reached a settlement. The Council previously told MI that the settlement terms are confidential.

Mr Prasifka said the rent for Kingram House has been published in accounts and he did not expect this procedure to change.

Registration timelines

Mr Prasifka said registration processing has improved and will progress further.

The Irish medical workforce stood at 20,473 doctors at year-end 2015, which is the highest number of doctors ever in the Council’s year-end statistics. This is an increase of 889 doctors on the previous year.

The Council has seen a significant increase in applications from doctors who qualified outside of Europe in the past year.  In 2015, just over 2,600 new doctors were registered, compared to 1,800 in 2014, with the majority of new doctors from outside of Europe.

Last year, the Council announced enhancements to registration processes for doctors who qualified outside the EU/EEA in order to “streamline their application process”. 

Mr Prasifka added: “The annual retention, as I understand it, goes extremely smoothly for the vast majority of practitioners and it is much easier now than it has ever been… Now, this was all started well before I came, but we are seeing the benefits of that and it is much easier now for doctors to register. It is happening much faster; the turnaround times for getting certificates and these kinds of things is much reduced.

“I am not saying things are perfect, but they are much improved to where they were even a relatively short time ago. But there are some resource issues there; we have requested some additional staff, and those requests are with the Department of Health and the Department of Public Expenditure and Reform.”

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