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from the President & CEO

O&G Magazine
Winter Report 2010

The winter edition of O&G Magazine’s theme is ‘Lightening: The third trimester of pregnancy’. Lightening is one of those delightful old terms, like attitude, denominator and station, that older consultants like to use to bamboozle medical students and junior doctors on ward rounds. It harks back to the era when obstetrics was, as it still is, a hands-on specialty, albeit with a changed set of clinical tools. This issue deals with common third trimester problems that we encounter frequently in practice, such as management of diabetes, the management of post dates pregnancy and counselling before an attempt at a vaginal birth after a previous caesarean section. Having just come from managing a 44-year-old obese woman, who was post dates, through labour, I can attest to the timeliness of these articles. I would like to thank all the authors of this edition of O&G Magazine for their invaluable contributions.

Since the last issue of O&G Magazine, there have been many areas of intense activity for Executive and Council and for College House staff. Some of these activities are highlighted below.

Release of NHMRC Guidance Document for Collaborative Care
The National Health and Medical Research Council (NHMRC) were tasked by the Australian Federal Government to develop a guidance document about collaborative maternity care, to underpin the  legislated maternity changes due to start in Australia in November 2010. The guidance was developed by a working party of approximately 20 health professionals from different areas of the maternity workforce. The group was chaired by Professor Chris Baggoley, an emergency medicine specialist, who is the current Chief Executive of the Australian Commission on Safety and Quality in Health Care (ACSQHC). There were two obstetricians on the group, myself and Professor Alec Welsh; one GP obstetrician, Dr Ruth Stewart; two representatives from the Australian College of Midwives, one midwife in private practice and one midwife from Belmont Hospital in Newcastle; two Maternity Coalition consumers; and a midwifery professor from Brisbane, who has extensive experience in rural and remote health, and in indigenous health.

The group developed a document which was then taken to a key stakeholder’s forum in Canberra in December 2009 and the document further developed to its present state. It has been sent to all Australian Fellows practising in obstetrics and NHMRC have had a group travelling to different states seeking useful feedback. RANZCOG will send a formal response to NHMRC.

Merging of RANZCOG and ACM Maternity Referral Guidelines
Side by side with this process is a process to merge RANZCOG and the Australian College of Midwives (ACM) Referral Guidelines, to produce a document that will underpin the proposed collaborative maternity reforms scheduled to commence in November of this year. RANZCOG has agreed with ACM to convene a small writing group which will work through the guidelines and produce a merged document for discussion. ACM requested that there be consumer representation on this group and RANZCOG agreed, on the proviso they were selected through a robust process and could clearly be seen to be independent consumer representatives. Concerns with the two consumers ultimately selected was expressed to NHMRC and, at the time of writing, the College is heartened by the understanding that the process will now involve the small writing group of RANZCOG and ACM representatives proposed initially, with consumer and other relevant stakeholder input gathered once that small group has produced a draft set of merged guidelines. I have committed RANZCOG to ensuring the merge does happen, but by a process that is fair and transparent.

The Australian Federal Government is very eager for the Referral Guidelines to be merged and see them as a way of being able to audit quality of practice, and possibly use them to make decisions on whether eligible midwives would be indemnified for their practice.

Another parallel process going on is the development of a safety and quality framework around the midwives, who have been granted exemption under the National Registration and Accreditation Scheme (NRAS) for the next two years. RANZCOG has been involved in discussions about this, with Professor Jeremy Oats and his team, and have insisted that matters such as vaginal birth after caesarean section (VBAC) at home must not be allowed under the framework. This group is also eager to see the release of the Referral Guidelines mentioned above, which will pronounce on place of birth, defining such things as when intrapartum care starts, what ‘failure to progress’ is, what the appropriate lengths of the different stages of labour are, etc.

National Registration

RANZCOG has received advice from the National Medical Board that they need to populate the specialist database and have requested the College to provide information from our databases to do this. We have sought legal advice and will progress this as appropriate. The new board is due to start functioning on 1 July 2010 and will greatly simplify registration. There will also be a better, more streamlined process for dealing with complaints to medical boards about doctors.

Practice Profile

Analysis of the practice profile has been completed and is now in the practice profile section of the RANZCOG website. It has two new questions. Fellows can look at the results of the profile so far, which is interesting, and complete the other two questions. It will be a useful data set when the proportion of Fellows completing it gets as close to 100 per cent as possible, which will help in workforce planning and in the planning of content for the training program.

PROMPT

It was announced at the RANZCOG 2010 Annual Scientific Meeting in Adelaide that the Victorian Managed Insurance Authority (VMIA) has secured the Australian licence for the PRactical Obstetric MultiProfessional Training course, appropriately named PROMPT, and have gifted it to RANZCOG. This is an exciting development and one that could be developed into a RANZCOG program which could be rolled out in Australia and New Zealand, recognising that PROMPT has already started in New Zealand, under Dr Martin Sowter’s capable direction. Dr Malcolm Barnett from Box Hill in Victoria is chairing a pilot group, and progress and outcomes of the project will have an evaluation at the end of 2010. Following that, if it is satisfactory, there will be an effort made to ‘train the trainers’, and the project developed in different states, along the lines of the Fetal Surveillance Education Program (FSEP). If delivered well, PROMPT should improve training and safety in maternity care, and fit in well with the collaborative maternity care models that are currently mooted.

RANZCOG 2010 Annual Scientific Meeting

The RANZCOG 2010 ASM ran from 21 to 24 March 2010 and was held at the Adelaide Convention Centre in South Australia. The theme of the meeting, ’It’s not all black and white’, encapsulated well the dilemma we face often as clinicians when trying to decide the best management for our patients, as well as reflecting the Adelaide Zoo’s proud acquisition of two pandas. A highlight of the meeting was a talk given by the chief vet for the pandas.

The meeting was very enjoyable and well-subscribed, with over 600 registrants. The Diplomates’ Day was oversubscribed and the workshops the day before the conference were fully booked. Overall, it was a very successful meeting, both scientifically and socially. I would like to pay tribute to Dr Chris Hughes and his organising team for the great job they did, and to Associate Professor Martin Oehler, Dr Jodie Dodd and the rest of the scientific team, for the scientific program which was exemplary in its interest and breadth.

Professor Alastair MacLennan delivered the Arthur Wilson Oration and gave a superb talk, much enjoyed by all.

The next RANZCOG ASM will be held in Melbourne in October 2011, so please mark it in your diaries.

GP Procedural Training Support Program

The Australian Federal Government is seeking to address structural and financial barriers that impinge on the capacity of individual doctors to increase their skills, and have provided financial support for GPs to improve their skills in obstetrics and anaesthetics, if they work in remote and rural locations. The program will provide support for 110 GPs over four years, with an aliquot of A$40,000 for each GP. The program is open to GPs who have commenced procedural training from July 2009 and is also open to DRANZCOG holders.

RANZCOG will be responsible for:
- Undertaking a selection process
- Promoting the program
- Financial support and entering into a fund-holding agreement with each GP
- Monitoring progress
- Monitoring DRANZCOG Advanced completion and notifying the department.

The program will be monitored by the General Practice Obstetrics Advisory Committee (GPOAC) and College House staff.

Accreditation of Practices Providing Diagnostic Imaging

The Australian Federal Government has set up the Diagnostic Imaging Accreditation Scheme. The legislation for this was passed in June 2007. Under the scheme, mandatory accreditation of providers of diagnostic imaging would be linked to the payment of Medicare benefits for radiology and non-radiology services.

When this was first mooted, the College had meetings with the Department of Health and Ageing, pointing out that the standard of accreditation for a radiology practice, or a practice dedicated to diagnostic imaging, such as obstetric ultrasound, should be different from that which applied to practitioners providing non-referred ultrasound in obstetrics and gynaecology in private rooms.  One of the reasons for this was because practitioners in obstetrics and gynaecology often use ultrasound in their rooms, as a clinical adjunct, to answer a specific clinical question, for example: ‘What is the presentation of a particular fetus?’ Used in this way, it provides a cost-effective alternative to referred ultrasound. Also, it was thought that the compliance and accreditation requirements for referred services, for things such as image capture and storage, reporting and notification of adverse findings, and medico-legal considerations, were vastly different when compared to a practice doing non-referred scans. RANZCOG was of the view that future accreditation requirements could be met through the College’s Continuing Professional Development program.

The Government, though, has tended to ignore that advice and has deemed that all providers of non-referred scans, if they intend to access Medicare benefits, must be registered for accreditation by 1 July 2010. I have written to the Fellowship about this, informing them of their need to register for the scheme before 1 July 2010, if they wish to charge Medicare for non-referred scans.

Health Workforce New Zealand  

The College has written and submitted an excellent document to Health Workforce New Zealand. This document will be crucial in helping the New Zealand Government plan their future workforce in obstetrics and gynaecology. The document highlights a number of areas of concern the College has about the obstetric and gynaecological workforce in New Zealand. These relate to the inequity of distribution of Fellows, the lack of subspecialists in different areas of practice, an undue reliance on overseas-trained specialists and the almost complete demise of the general practitioner obstetrician.

Seventh RANZCOG Council

Nominations will be called soon for Fellows to nominate for election to RANZCOG Council. This will be a ground-breaking Council, as it will be the first to operate under the recently approved new governance structure and will work with the Executive Board. I would encourage you strongly to nominate for election, as it is important that the College’s Fellows keep coming forward to give their time ‘pro bono’ in the running of the College. Involvement in Council can be immensely rewarding professionally, intellectually and socially. I would suggest you give serious thought as to how you, wherever you are in your professional life, could contribute to RANZCOG, your professional body.

Finally, I wish to congratulate Dr Rupert Sherwood on his successful election as the next RANZCOG President and wish him well during his term in office. As mentioned above, it will be an interesting time, with an Executive Board working with Council and with Council meetings adopting a different format.

Dr Ted Weaver

President

O&G Magazine
Winter Report 2010

It is a personal and professional privilege to have been given the opportunity to lead the team whose task it is to assist those responsible for the governance of RANZCOG with the development and implementation of strategy and operations that enable RANZCOG to remain a relevant and effective organisation.

Like the practice of obstetrics, in which I have no experience, the question has been much asked and discussed in regard to whether the act of leading and managing in such a role is art or science. As with the theme for this edition of O&G Magazine, the answer is not clear cut. There is almost always acknowledgement of the need for a certain amount of science, but also the realisation that the construct being discussed is a gestalt phenomenon where the whole is greater than the sum of the parts. To simply be able to recite appropriate literature and the contents of how-to manuals is not enough. Like obstetrics, leading and managing is an intensely human activity not on the same life and death scale, of course but still on a level that affects individuals in an organisation on a daily basis and which must be practised with an eye for the affective components involved.

There are many parallels that can be drawn with the discussions in medical education relating to assessment when one considers the evaluation of leadership; assessment of low-level cognitive competencies is relatively straightforward and most people can tell you what good, effective leaders should do. At the other end of the spectrum, the assessment of higher order capacities is more difficult and the proof is very often in the eating; that is, the mark of an effective leader, with the management component which that entails, is really only seen when some sort of performance-based assessment is employed. In simple terms, can someone do the business, rather than simply talk the talk? Art or science? So much of human activity increasingly involves a measure of both. The proportions may vary, but having sufficient of each to perform effectively under varying conditions may increasingly be what really matters.

As I write this report, there is the realisation that the term of this Council is essentially at its half-way point, with arrangements for the meeting of Council and its committees in full swing, along with the annual general meetings of both the College and the RANZCOG Research Foundation. The festive season is approaching and it is this time, perhaps more than any throughout the year, that provides a stimulus to reflect on what has occurred through the calendar year, what is still undecided and what is requiring further resolution in the coming year.

As always, there has been much activity, both within and outside the College, since the previous meeting of Council, with developments such as the passing of Bill B that underpins the National Registration and Accreditation Scheme (NRAS) and the constitution of the Australian Health Practitioners Regulation Agency (AHPRA); and the Medical Board of Australia to facilitate the operation of the scheme. There has been further activity at government level in relation to the shape that maternity reforms in Australia will take, while in New Zealand, as in Australia, there appears much activity at Ministry level in regard to reform of the overall health sector.

There is particular activity in Australia associated with health workforce planning and I would encourage members wishing to gain an overview of the activity to access the website of the National Health Workforce Taskforce at: www.nhwt.gov.au/ . As part of the initiatives aimed at accommodating increased postgraduate vocational trainees in future years, the Commonwealth remains committed to the investment in funds to encourage specialist training in expanded settings, therefore, outside the traditional public teaching hospitals. The program relating to this is now known as the Specialist Training Program (STP) and, as a result of a 2009 Federal Budget initiative, now incorporates a number of previously separate programs, including the Outer Metropolitan Specialist Trainee Program (OMSTP) and the up-skilling program aimed at overseas trained specialists working toward Fellowship of a specialist medical college. Application processes for proposed positions to begin from 2011 are intended to commence soon and the College will assist in publicising the details as soon as they become known.

As well as the consolidation of a number of programs in relation to specialist training, the 2009 Federal Budget also saw the consolidation of a number of programs relating to continuing professional development for specialists, including the Support Scheme for Rural Specialists (SSRS). While the initial intention was to amalgamate the SSRS program with other programs, recent communication has indicated an extension of the SSRS program until the middle of 2010, with details of the exact nature of the future funding arrangements (therefore, a separate, stand-alone program or amalgamated with others) not clear at this time.

By the time this edition of O&G Magazine is being read, Council will have further considered the matter of College governance arrangements, a matter that, increasingly, those who are involved with the governance of the College realise is in some need of attention. A review of the overall College activities from a risk management perspective has been undertaken and completed, providing an up-to-date risk profile for the organisation. Members can be assured that identifying and mitigating potential risks to the College is something that all involved in College governance are very much aware of and looking to address in an increasingly systematic manner. That said, however, we operate a somewhat distributed organisation in dynamic times and this, in and of itself, presents challenges for us.

As anticipated, the appointment of a Director of Education and Training has been a valuable strategic move for the College. It has enabled the progression of activities that will assist us in ensuring we are progressing the core business, for which the organisation exists, in a manner that is expected from all stakeholders, both internal and external. Currently, there is much activity in relation to what is essentially the core business of the College, with much more to be debated and implemented over time. As a snapshot, the following are of note:

• A review of the content of the RANZCOG Curriculum (therefore the FRANZCOG training program);
  
• A review and revision of the Flexible Learning Program (FLP), construction of online modules to support the research project requirement of the FRANZCOG training program and online training supervision modules to assist those undertaking the important role of supervising trainees;
  
• The trial of a revised continuing professional development (CPD) framework aligned to the RANZCOG Curriculum;
  
• The development of new curricula for the DRANZCOG and the DRANZCOG Advanced under the auspices of the Conjoint Committee for the Diploma of Obstetrics and Gynaecology (CCDOG), the body now responsible for the oversight of the Diploma qualifications; and
  
• Continuing review of the assessment processes for overseas trained specialists to ensure they are as robust and fit for purpose as possible.

Along with the President, I recently attended the 19th FIGO Congress in Cape Town, South Africa. The meeting was a well-organised event with a large number of delegates. My attendance enabled a better understanding of the work of FIGO and some of its member organisations in the context of possible partnerships and initiatives in which RANZCOG could become involved. This was particularly so in relation to initiatives surrounding the United Nations Millennium Development Goal Five (MDG 5)1 that aims to improve maternal health, with two articulated targets:
1. Reduce by three quarters the maternal mortality ratio.
2. Achieve universal access to reproductive health.

According to the United Nations website, the following points are made in regard to Target One:

• The high risk of dying in pregnancy or childbirth continues unabated in sub-Saharan Africa and Southern Asia;
  
• Little progress has been made in saving mothers lives; and
  
• Skilled health workers at delivery are key to improving outcomes.

In regard to Target Two:

• Antenatal care is on the rise everywhere;
  
• Adolescent fertility is declining slowly; and
  
• An unmet need for family planning undermines achievement of several other goals.

The above notwithstanding, there are localised examples of where good progress has been made in regard to MDG 5. However, there is clearly more that needs to be done, in some cases in regions and countries that RANZCOG is very aware of and familiar with. There are opportunities for the College, through the Asia Pacific Committee and in conjunction with other organisations, to play a role in furthering the achievement of MDG 5 in those places.

The College has had conversations with the Australian Parliamentary Secretary for International Development Assistance, the Hon Bob McMullan, in an effort to make further links with AusAID and other potential partners, to facilitate capacity-building that will enable us to make positive contributions in this area. In conjunction with the Pacific Society for Reproductive Health (PSRH), the College also made a written and verbal submission in September to a hearing on maternal health in the Pacific, conducted by the New Zealand Parliamentarians Group on Population and Development (NZPPD). Attendance at the hearing was useful in terms of enabling an understanding of the contributions being made by a range of groups, who are currently undertaking activities in regard to this aspect of College work. The knowledge gained will also assist in the formulation of strategies and initiatives for the Asia Pacific Committee to consider.

The College's Annual Accreditation report to the Australian Medical Council (AMC) was submitted in September and my thanks go to all involved in its compilation. As well as indicating to an independent external body the activity that has been undertaken by the College in relation to the areas covered by the standards in the time since the previous report was submitted, the reports enable the College to assess its progress in what are essentially its core business areas; that is, education and training (including assessment) and CPD. Of interest is that there are still recommendations from the original accreditation report of 2003 that are pertinent to the evolution of the College today and on which we are still asked to comment. It is important that we use the accreditation process and the feedback to our annual reports from the AMC to guide us in a way that is strategic, as well as addressing some specific aspects of the training and CPD programs.

It is my intention, in conjunction with the Director of Education and Training and the chairs of relevant College committees, to undertake a systematic audit of the accreditation standards to ensure that the College has up-to-date policies and procedures in place in relation to the major of aspects of core business covered by the standards. This is in addition to any strategic initiatives that may be undertaken as part of the evolution of College activities in relation to areas covered by the standards.

Of note, also from the AMC, is the production of the document Good Medical Practice: A Code of Conduct for Doctors in Australia. The code was developed in the context of the move to a national system of registration for medical practitioners in 2010 under NRAS and included wide consultation with a range of stakeholders, including the specialist colleges. The code may be accessed at: http://goodmedicalpractice.org.au/ . Councillors may also be interested in the document recently published by FIGO, Ethical Issues in Obstetrics and Gynecology by the FIGO Committee for the Study of Ethical Aspects of Human Reproduction and Women's Health (www.figo.org/about/guidelines).

The last weekend of October saw the holding of MedEd09, a conference covering all stages of the so-called continuum of medical education in Australia. Convened under the auspices of Medical Deans Australia and New Zealand (MDANZ), the conference was sponsored by MDANZ, the Australian Government Department of Health and Ageing, the Australian Medical Council (AMC), the Committee of Presidents of Medical Colleges (CPMC) and the Confederation of Postgraduate Medical Education Councils (CPMEC). The conference theme was Investing in Our Medical Workforce. I was fortunate to be involved with the organisation as a nominated representative of the CPMC, while RANZCOG Fellow, Professor Judy Searle, was also part of the organising group. The Director of Education and Training attended the conference, former RANZCOG President, Dr Ken Clark, spoke on the program about the New Zealand perspective of health workforce and education, and Dr Jolyon Ford spoke about Recognition of Prior Learning as part of a session titled Achieving Vertical Integration.

The conference was held at a time where many initiatives relating to health workforce and training are being undertaken, some at more advanced stages than others. The international keynote speaker for the conference was Sir John Tooke, Dean, Peninsula College of Medicine and Dentistry, Universities of Exeter and Plymouth, UK. Professor Tooke chaired the Independent Inquiry into Modernising Medical Careers, following the problems associated with the Medical Training Application Service (MTAS) process, with the final report of the inquiry published in January 2008.

Based on activities at the conference, it is the intention to produce recommendations relating to health workforce and training for consideration by stakeholders. Draft recommendations produced during the conference related to areas such as Commonwealth and State coordination of medical education; the role of competency-based training in medical education; the role of the generalist in the Australian health workforce; the importance of adequate resourcing of training institutions; the acknowledgement of the role of supervision in job descriptions; and the relationship between service delivery and training.

Finally, as the end of the year approaches, I would like to thank all involved in progressing the work of the College during 2009. Again, much has been achieved and still the list of what remains shows little sign of waning. Not for the first time, I have referred above to the exciting, yet turbulent, time and environment in which the specialist colleges are operating. It is incumbent on us all who are involved in the stewardship of RANZCOG to ensure that we strive to act in the true tradition of such stewardship and leave the organisation in better health than when we encountered it, so that the next generation may look with appreciation on what has been achieved during our period of involvement.

I wish all College members, staff and their families a happy and satisfying holiday season. I look forward to the challenges that 2010 will bring us as we once again take on the task of stewarding RANZCOG for the future.

Reference
1. www.un.org/millenniumgoals/maternal.shtml#mdgs .

Dr Peter White

CEO