Non-Teaching Hospitals - Memorandum of Understanding

6 February, 2001

Click here to view full copy of Memorandum of Understanding

The AMA and the Minister have concluded an agreement on the Memorandum of Understanding on the governance of non teaching hospitals. This advice follows on from various publications in Medicus and the advice distributed on 6th December 2000 to practitioners summarising the Association's position in relation to the draft contracts and the development of the MOU and requests for input.

The MOU reflects a refinement of processes previously negotiated by the AMA (WA) over many years. It endeavours, in the light of concerns across the system, to reinvigorate medical input into the management of hospitals and ensure appropriate professional standards are protected against economic rationalists within health bureaucracies.

The MOU, which is set out in a 20 page document, covers amongst others, the following areas:

Hospital Boards and Medical Practitioners

This section importantly provides that:

1. Access: Medical practitioners practicing in the local community will, subject to meeting the requisite standards, have a presumption of having access to the local hospital to be able to compete for access to its resources and treat patients.
2. Clinical Independence: With clear recognition that subject to the Board's over-riding duty of care to patients and clinical privileges/contractual conditions, Hospital Boards will not control or be responsible for clinical decisions of medical practitioners in relation to admission, treatment or discharge of a patient.
3. Accountability: Recognition by the Board that medical practitioners are personally responsible to their patients and responsible and accountable to : (a) the Medical Board and other statutory authorities, (b) ethical codes of standards of relevant colleges and professional associations and hence the Board cannot seek to over-ride those obligations reinforcing clinical independence.

Medical Advisory Committees

The MOU sets out the constitution and role of the MAC and its chairman. The MAC has the fundamental role of advising the Hospital Board on:

1. Medical policy and matters affecting patient care;
2. Medical workforce issues and medical requirements of the healthcare facility;
3. Efficient and equitable use of hospital resources, including theatre utilisation policy unless this has been delegated elsewhere; and
4. other matters.

The role of the MAC Chairman includes reviewing the adequacy of Emergency Services Roster at the healthcare facility and endeavouring to reconcile healthcare facility and community requirements having regard for the availability of medical practitioners and occupational, health and safety considerations. Importantly, the Chairman of the Medical Advisory Committee is an ex-officio member of the Executive Committee of the healthcare facility and the MAC, if it is unable to resolve any significant issue between itself and the Hospital Board is entitled to pursue the matter with the Minister for Health. These provisions enhance the status of medical input and provide for direct representation to the Minister if difficulties with hospital management occur.

Clinical Privileges Advisory Committees (CPAC)

These committees are established under the MOU to advise the Board on applications for clinical privileges and review clinical privileges of existing practitioners periodically through appropriate peer review processes etc.

As stated earlier, the MOU provides a presumption that local practitioners will be accredited if they meet the requisite standards in those areas consistent with the role of the hospital and be able to compete for access to the hospital to ensure they are able to treat their patients. This had been under severe threat. The Clinical Privileges Advisory Committees will need to ensure that they conduct themselves in accordance with the the principles/criteria set out in the MOUand judge applications on their merit. Where applicants may be in potential competition with members of the CPAC, reference should be made to the conflict of interest and proxy provisions of the MOU to determine the appropriate approach.

A medical practitioner practicing in the local community who is not granted access to the hospital, may appeal to a Medical Appeals Panel constituted under the MOU. A practitioner whose privileges are adversely reviewed, may similarly appeal. This provides significant protection which otherwise would not have been available.

Review of Clinical Conduct

This section is very complex and has been developed to seek to ensure that proper processes apply where medical practitioners are subject to complaints or where concerns are expressed over their clinical competence etc. The provisions provide important safeguards for practitioners who experience difficulties and provide appropriate mechanisms to determine whether they meet the requisite standards and can continue to practice in those areas or mechanisms need to be in place to bring them up to standard, alter their clinical privileges or otherwise be dealt with. Given the fundamental obligation to protect patients from harm etc, there is recognition of the right of a Hospital Board to suspend a practitioner either generally or in relation to specific areas of practice and appeal provisions against such actions. Members are urged to read the document in full to appreciate the mechanisms that have been developed to protect and balance their and their patients' interests.

There is an undertaking by Government to also seek to address issues of indemnity for member serving on committees, providing advice and reviewing clinicians conduct, etc by 30th June.

Conclusion

The MOU is a complex document that has taken a huge amount of work by the AMA in terms of its development, technical input, legal advice and negotiations with Government at Officer, Commissioner and Ministerial level. It represents a significant development in seeking to safeguard individual doctor's rights to compete for access to the hospitals resources, to maximise medical input into the management and operations of the hospital and provide proper processes for reviewing the clinical competence of doctors without the need to resort to matters being taken to the Medical Board etc. It presents a major opportunity for doctors to input into the operations of the hospital and ensure that appropriate standards are practised and maintained.

The commitment to clinical independence and rights of access for community based practitioners are fundamental achievements which have been under great threat. The MOU however, only represents one facet of the Association's overall strategy and also needs to be complimented by practitioners own actions in supporting the processes in investing in the management of public hospitals and ensuring that their contract reflects their needs.

Further information and advice will be published in Medicus.

Stop Press: Insurances/Indemnities, etc

The AMA is continuing to make representations within the limits of the Trade Practices Act over concerns with the draft contract with respect to indemnities, insurances, workers compensation cover, intellectual property and other issues. The relevant provisions are being re-evaluated by Government with a number of changes likely to result. Members should ensure that any such changes meet their particular needs and are acceptable to their medical defence organisation and insurer(s).