Correspondence

Dear Sir,

I feel it is important to clarify and expand on comments made in my letter to Australasian Psychiatry (published May 1999) – and the response by Dr Janice Wilson published in the same issue. My letter confused (and I freely acknowledge this) the CPMC (Committee of Presidents of Medical Colleges) with the issue of the ‘Academy of Medicine’ which Dr Wooldridge did encourage, but the two are interconnected as we will see below. The concerns expressed remain unchanged. Their importance lies in the relevance of these issues to College processes (i.e. transparency of governance) and to the dangers that face psychiatric practice as we know it. These issues do not, in my opinion, reflect ‘a difficulty with change’ as Dr Wilson suggests in her President's Letter (Australasian Psychiatry May 1999) – it's a question of what kind of change. In my letter, I raised concerns over the role of the CPMC in negotiating with (what I and others perceive to be) an inherently hostile Government. I felt this Government was not concerned fundamentally with the equity and social justice issues which so many of our patients face. The CPMC, in that role, was unaccountable.

The facts in this matter are instructive. In 1997 the CPMC was instrumental in proposing the formation of a peak body to negotiate with Government, known as ‘The Academy of Medicine’. In fact, this body underwent two name changes since then but remains under the Chairmanship of Dr Peter Phelan, a paediatrician and President of that College. In a memo from Dr Phelan (21/1/98) to all Presidents we found the following points in regard to the function of this organisation:

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we will be involved in political issues but from a different perspective than the AMA

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that the AMA needs to confront its limits in its ability to influence health policy

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the Secretary of the Commonwealth Dept of Health & Family Services would be very keen to see a dialogue with senior officers on evolving health policy

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quality of health care is a systems issue requiring coercive measures

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it may have a view on the processes by which fees & relativities were developed’.

Clearly then, the proposed activities of this organisation go well beyond what Dr Wilson describes as ‘joint endeavours in such areas as specialist training’. What Dr Wilson describes as something of a virtue (‘providing authoritative advice’) I see as a real danger, given the range of topics for discussion, and the risk of splitting the profession.

After much protest this proposal to form the Academy of Medicine was put to one side. However, this ‘controversial plan is gone but not forgotten’ and ‘there appears to be emerging in its place a cut-down version of the same idea’ (Australian Doctor 6/11/98). The same article voiced concerns from various quarters that this was ‘a way for the Government to split the profession’, precisely the concern I expressed.

As one surgeon put it – ‘the real problem is that those who serve on Councils of Colleges who made the decision to set up the Academy had no mandate to do so … it is not accountable to Fellows’ (private letter 18/2/98). I agree – and I further agree with his view that we currently do not elect our Presidents on their political track record (at least not explicitly) and perhaps this warrants closer scrutiny.

As noted above, the idea of the Academy has not disappeared. In particular, in May 1998 two companies were incorporated with Dr Phelan as a Director of both — viz: The ANZ Academy of Medicine, and The ANZ Academy of Colleges.

The Memorandum of Association of the latter states its intention to ‘work with Government’ … ‘with particular emphasis on health policy and negotiation with Govt.’

Documents obtained under Freedom Of Information provisions from the Dept of Health & Family Services show quite clearly that the potential agenda for ‘the Academy’ as seen by the Department includes finding an alternative to the AMA, work practices (and remuneration) and ‘a highly contentious subset of work practice issues … the issue of clinical freedom, which relates to the resistance to contracting’ (email 6/1/98).

There is no reason to suppose the agenda has changed just because the names have changed, the two new companies quietly replacing their predecessor.

In October 1998, the President of the RACS circulated a letter outlining a proposal to change the name of the CPMC into the ‘Confederation of Medical Colleges’, adding that it was not imperative. However he included a draft of a Charter & Rules for the body to better define its activities. In particular he noted the inclusion of ‘Veto and Non-Binding Provisions’ which ‘enables any College that does not believe a particular proposal is in its own best interest to veto that proposal’ (clause 33.1.2).

If we cast our mind back to February 1999 and the MACC Project (Measures of Appropriate Clinical Care), there we saw clinical autonomy threatened by the deliberations of a committee heavily subsidised by the Health Insurance Industry — with the Chair of the CPMC Dr Phelan, and therefore psychiatry indirectly, in attendance. The MACC project was only withdrawn after much media attention and AMA lobbying. Is it not reasonable to ask if it was wise that we were indirectly represented, given our experience with item 319? Is it not reasonable to wonder how useful a veto would be if it were to be exercised by a Chair of a large committee, and the President of another College with differing interests from our own? The latter problem is amply demonstrated if we note that not all members (Presidents of RANZCP & RACS) of the CPMC knew of the MACC project which Dr Phelan had committed them to. So what use is a veto provision?

It is noteworthy to include here, that it would appear that proponents of this role for the CPMC held the view that the veto provisions amount to a disempowering of the CPMC (1/2/99 letter from RACP to Dr Phelan). How much power does it want? Do these sorts of statements give Fellows any confidence at all that this body can remain truly independent of Governmental influence and manipulation and advocate for our patients?

The Dept Of Health & Aged Care recently (28/1/99) wrote to the CPMC to enlist their support in a visit by a Dr B James, of Intermountain Health Care, Utah – a health care organisation. The Dept intends to fund the visit for ‘key stakeholders in health policy’, to discuss ‘quality’ health delivery. One can only wonder about the implications of this given the Government's commitment to the introduction of managed care strategies (by whatever name) into this country, and the lack of detail available about the agendas behind this visit. But the point is that the Department initiated this.

Therefore in conclusion, one can say that the CPMC is involved in more than just training and issues of standards, and that the Government is actively courting this. That Presidents are accountable, as Dr Wilson states, is a moot point: Presidents are elected by Council and not general Fellows, they are not remunerated, and both these factors not only skew their selection but raise questions about their level of accountability. To whom are they immediately accountable?

Further, it is not clear to me that all of the above details/facts (the current existence of the two Academies, the policy role of the CPMC for example) have been regularly detailed at General Council. A cursory enquiry of a local Councillor revealed a complete lack of knowledge of the above information.

I do feel very strongly that there is a need to advocate for our independence, and for our patients' right to whatever treatment is appropriate clinically — i.e. not as determined by Government or their Committees. I still maintain that the role the CPMC appears to be embracing is not one mandated by Fellows, and that it does demonstrate an alarming underestimation of the manipulativeness and hostility in Government policy towards the most vulnerable in our society. More importantly, no matter how good our intentions, we cannot necessarily control such a body, as the experience with the MACC project demonstrates.

We must be wary of a ‘culture of committees’ which pervades our bureaucracy, when it leads to autonomous action that may not be in keeping with the wishes of the wider constituency of the College. Setting up a Committee does not necessarily mean we are achieving anything. We must also continually reserve our right to criticise, rather than be put off by attempts to silence critique that try to appeal to us to listen to ‘distilled wisdom’. Otherwise we risk the College truly becoming irrelevant, not to Government, but to its own members as other correspondents (Australian Psychiatry, May 1999) pointed out.