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Medicine – a Profession Guidelines and Regulations Prof Orla Sheils Department of Histopathology TCD Medicine – a Profession Guidelines and Regulations Prof Orla Sheils Department of Histopathology TCD

Medicine – a profession • Major attributes of a profession – Acquisition of learning Medicine – a profession • Major attributes of a profession – Acquisition of learning prior to practice – Requirement for continued learning after qualification – Separate sense of identity – Ethical code of conduct

Statutory and non-statutory professions • Statutory – Profession is backed by law – Law Statutory and non-statutory professions • Statutory – Profession is backed by law – Law creates a regulatory body • Supervisory and disciplinary powers – Self-regulating with deference to the laws of the state • Non-statutory – More loosely affiliated – Representing body without regulatory or disciplinary powers

Examples: • Statutory • Non-Statutory • • Physiotherapists • Radiographers • Occupational Therapists • Examples: • Statutory • Non-Statutory • • Physiotherapists • Radiographers • Occupational Therapists • Speech Therapists • Social Worker • Dietician • • Doctors(Medical Practitioners Act 1978) Dentists (Dentists Act 1985) Nurses (Nurses Act 1985) Pharmacists (Pharmacy Act (Ireland) 1875, Pharmacy Act 1962) Opticians (Opticians Act 1956)

Statutory Regulatory Bodies are responsible for: • Defining ethical guidelines • Overseeing disciplinary issues Statutory Regulatory Bodies are responsible for: • Defining ethical guidelines • Overseeing disciplinary issues and fitness to practice of members – Generally suspension or removal from register is conducted under supervision fo the High Court • Maintaining a register of practitioners

Statutory Regulatory Bodies • Created by a specific law which empowers them to oversee Statutory Regulatory Bodies • Created by a specific law which empowers them to oversee and regulate aspects of the profession. – Medicine • Medical Council – Medical Practitioners Act 1978

 • The Medical Council protects the interests of the public when dealing with • The Medical Council protects the interests of the public when dealing with registered medical practitioners. • The Council was established by the Medical Practitioners Act 1978 and commenced operation in April 1979. • “It shall be a function of the Council to give guidance to the medical profession generally on all matters relating to ethical conduct and behaviour”

 • The Medical Council is funded exclusively by the annual payments of registered • The Medical Council is funded exclusively by the annual payments of registered doctors; no funds are received from government or other sources. • The annual retention fee for a fully registered doctor has been set at € 475 from 1 st July 2008. • On 1 st January 2008 there were, in total 18, 316 doctors, of the various registration categories, registered with the Medical Council. 8

Medical Council • Elections held every 5 years • 25 members - representatives – Medical Council • Elections held every 5 years • 25 members - representatives – Irish Medical Schools – RCS (surgery and anaesthetics/radiology) – RCPI (Medicine and Pathology and Obs and Gynae) – Psychiatry, General Practitioners – Medical Practitioners elected from the profession – Ministerial Appointees

Medical Council- Breakdown • 25 members – 5 appointed by authorities of medical schools Medical Council- Breakdown • 25 members – 5 appointed by authorities of medical schools in the State. – 6 appointed to represent medical and surgical specialities, psychiatry and general practice. – 10 registered practitioners elected by the profession – 4 people appointed by Minister for Health (at least 3 of whom must come from outside the medical profession).

Current Members of Medical Council Professor Kieran Murphy (President) Medical Practitioner Nominated by Irish Current Members of Medical Council Professor Kieran Murphy (President) Medical Practitioner Nominated by Irish Psychiatric Training Committee Mr Frank Mc. Manus Medical Practitioner Nominated by Royal College of Surgeons in Ireland Mr Jon Billings Non-medical member Nominated by the Health & Quality Authority Dr Anna Clarke (Vice-President) Public Health Medicine Elected member Dr John O'Mullane Non-medical member Health & Social Care Professionals Council Ms Anne Carrigy Non-medical Member Nominated by An Bord Altranais Dr Daniel O'Hare Non-medical member Nominated- Independent Hospitals Assoc. of Ireland Professor Anthony Cunningham Anaesthesia Elected member Dr Regina Connolly Non-medical member Ministerial Nominee Dr Deirdre Madden Non-medical member Ministerial Nominee Ms Margaret Murphy Non-medical member Ministerial Nominee Dr John Monaghan Obstetrics & Gynaecology Elected member Dr Pauline Kane Non-Consultant Hospital Doctor Elected member Dr Richard Brennan Medical Practitioner Nominated - Irish College of General Practitioners Ms Mary Culliton Non-medical member Nominated by the Health Service Executive Ms Katharine Bulbulia Non-medical member Ministerial Nominee Dr Éamann Breatnach Elected member Radiology Mr Brendan Broderick Non-medical member Nominated by the Health Service Executive Professor Damien Mc. Loughlin Non-medical member Ministerial Nominee Professor Paul Finucane Medical Practitioner Nominated by the University of Limerick Professor Diarmuid O'Donoghue Medical Practitioner Nominated - Royal College of Physicians of Ireland Professor William Powderly Medical Practitioner Nominated by University College Dublin 11

The principal roles of the Medical Council include: • assuring the quality of undergraduate The principal roles of the Medical Council include: • assuring the quality of undergraduate education of doctors • assuring the quality of postgraduate training of specialists • registration of doctors • disciplinary procedures • guidance on professional standards / ethical

Medical Council • Maintains register of practitioners – Full, provisional or temporary • “Full Medical Council • Maintains register of practitioners – Full, provisional or temporary • “Full registration is available to any doctor who has a recognised medical qualification together with recognised and verifiable experience, either prescribed by law or acceptable to the Medical Council, as a practitioner. ” • Doctors from Ireland EU entitled to full registration

Registration • Full registration – This permits a doctor to work as an independent Registration • Full registration – This permits a doctor to work as an independent practitioner. • Internship Registration – This permits a doctor to carryout internship training in approved hospitals. Internship training normally begins immediately after graduation from medical school and lasts for one year. Only graduates of Irish and EU medical schools may do their internship in Ireland. • Temporary Registration – This form of registration allows non EU doctors to practise medicine in approved hospitals under consultant supervision in a specialty recognised by the Medical Council.

Registration • Register of Medical Specialists – contains the names of registered specialists. – Registration • Register of Medical Specialists – contains the names of registered specialists. – Register of Medical Specialists is a voluntary register. Only doctors who currently hold full registration in the General Register of Medical Practitioners may apply to have their names entered in the Register of Medical Specialists. – If a doctor removes his/her name from the General Register they are automatically removed from the Specialist Register.

It is an offence under the Medical Practitioners Act for a doctor to falsely It is an offence under the Medical Practitioners Act for a doctor to falsely represent himself/herself to be a registered medical practitioner when they are not registered.

Medical Council Register • Register of Medical Practitioners – Medical insurance companies require registration Medical Council Register • Register of Medical Practitioners – Medical insurance companies require registration before insurance cover is given. – Registration is required to sign medical certificates and to issue prescriptions for certain categories of drugs. – Doctors are not entitled to recover in legal proceedings, fees charged for the provision of medical or surgical advice or treatment given when they were not registered. • Register of Medical Specialists – Expected to enrol once training is complete • Public Document – May be inspected by any member of the public

Medical Council - Education • Assess Training and Education of training centres • Input Medical Council - Education • Assess Training and Education of training centres • Input into curricula and level of experience deemed necessary • Postgraduate Medical Board – specific responsibility for postgraduate training.

 • The Medical Practitioners Act, 1978, states that it shall be the duty • The Medical Practitioners Act, 1978, states that it shall be the duty of the Council from time to satisfy itself: • (a) as to the suitability of the medical education and training provided by any body in the State recognised by the Council for such purpose, • (b) as to the standards of theoretical and practical knowledge required for primary qualifications, • (c) as to the clinical training and experience required for the granting of a certificate of experience, and • (d) as to the adequacy and suitability of postgraduate education and training provided by bodies recognised by the Council for the purposes of medical specialist training. 19

Medical Council-Disciplinary Function • Area which has occasioned much interest • Combination of proactive Medical Council-Disciplinary Function • Area which has occasioned much interest • Combination of proactive and reactive/punitive approaches

Medical Council-Disciplinary Function • Proactive: – Publication of guidelines • Benchmark for medical practice Medical Council-Disciplinary Function • Proactive: – Publication of guidelines • Benchmark for medical practice – Competence Assurance • Ongoing confirmation of clinical standards • Continuing education • Clinical audit

Medical Council-Disciplinary Function • Punitive/Reactive measures regarding misconduct or fitness to practice: – Censure Medical Council-Disciplinary Function • Punitive/Reactive measures regarding misconduct or fitness to practice: – Censure or admonishment – Attachment of conditions to continuing practice – Suspension from the register – Erasure from the register

Medical Council-Disciplinary Function • Disciplinary decisions regarding suspension or erasure from register MUST be Medical Council-Disciplinary Function • Disciplinary decisions regarding suspension or erasure from register MUST be approved by the High Court. • Council can request an immediate order of the Court, enforcing suspension if it is deemed to be in the public interest.

Professional Misconduct • ‘…conduct which doctors of experience, competence and good repute, upholding the Professional Misconduct • ‘…conduct which doctors of experience, competence and good repute, upholding the fundamental aims of the profession, consider disgraceful and dishonourable…. ’ • Must have an element of moral failure or persistent recklessness/negligence

Fair procedure and disciplinary matters • Irish Constitution declares the administration of justice is Fair procedure and disciplinary matters • Irish Constitution declares the administration of justice is reserved to judges. • Court requires to know that any decision was based on reasonable and if fair procedures were followed in making the decision.

Fitness to practice • The Fitness to Practice Committee consists of members of the Fitness to practice • The Fitness to Practice Committee consists of members of the Medical Council, of which, the majority must be elected and include at least one lay member. • At present the three lay members appointed by the Minister for Health to represent the public interest sit on the Fitness to Practice Committee.

Fitness to practice • The Fitness to Practice Committee of the Medical Council has Fitness to practice • The Fitness to Practice Committee of the Medical Council has a statutory duty under Part V of Medical Practitioners Act, 1978 to consider complaints made by the Council or any person into the conduct of a registered medical practitioner on the grounds of: – his/her alleged professional misconduct and/or, – his/her fitness to engage in the practice of medicine by reason of physical or mental disability.

Fair procedure and disciplinary matters • • • Delay – Timely investigation, as delay Fair procedure and disciplinary matters • • • Delay – Timely investigation, as delay can hinder a person’s ability to defend themselves. Notice – Requirement for due notice so a person can prepare a defence Hearing – Generally presented by barristers – Cross-examination Reasons – Full reasons regarding any decision must be provided –to facilitate appeal if appropriate Prejudice and Bias – Unfair if a person has already made up their mind – Bias- more subtle, financial interest, personal or political position Proportionate nature of censure – Punishment should fit the crime

Irish Healthcare system • Mix of public and private funding. • Everyone is entitled Irish Healthcare system • Mix of public and private funding. • Everyone is entitled to free public inpatient and outpatient care in public hospitals should they wish to avail of them.

Irish Healthcare system • Administration and delivery of services – – Legislature Minister Department Irish Healthcare system • Administration and delivery of services – – Legislature Minister Department of Health and Children Health Service Executive and regional health authorities – Others e. g. : • • Irish Medicines Board Health Research Board Comhairle ns n. Oispidéal IBTS

HSE • Up until January 2005, public health and personal social services in Ireland HSE • Up until January 2005, public health and personal social services in Ireland were delivered by a network of ten health boards, located throughout the country. • Health and personal social services in Ireland are now delivered by the Health Service Executive, through a network of Local Health Offices, health centres and clinics.

HSE • Each Health Service Executive Administrative Area is responsible for the provision of HSE • Each Health Service Executive Administrative Area is responsible for the provision of health and social services in its area. • They provide many of the services directly and they arrange for the provision of other services by health professionals, private health service providers, voluntary hospitals and voluntary/community organisations.

Duty of HSE to provide services • The HSE Area is obliged to provide Duty of HSE to provide services • The HSE Area is obliged to provide certain services, e. g. , family doctor (GP) and public hospital services. • There are other services that they may provide, e. g. , home helps and other community care services. • A significant part of the HSE Area's overall budget is allocated to those services that are obligatory.

Suggested Reading • Clinical Practice and the Law – Simon Mills • Law and Suggested Reading • Clinical Practice and the Law – Simon Mills • Law and Medical Ethics – Mason, Mc. Call Smith, Laurie • Medicine Ethics and the Law – Deirdre Madden • http: //www. medicalcouncil. ie