Chapter 1 Conduct and context of the inquiry
Australia has one of the best healthcare systems in the world,
delivering consistently high quality of care. A qualified, trained and skilled
workforce is a key component to the success of the healthcare system, including
an adequate number of medical practitioners. The vital contribution that
international medical graduates (IMGs) make to this system is
widely recognised and valued. Although Australia’s reliance on medical
practitioners who have qualified and trained overseas has varied over time, it
is estimated that IMGs currently represent an estimated 39% of registered
medical practitioners. It also seems that Australia will continue to need IMGs
to maintain its medical practitioner workforce.
In view of this continued reliance on IMGs, the challenge is to
establish a system which enables suitably qualified and experienced medical
practitioners to work in Australia, while also protecting the health and
wellbeing of the Australian public. With the latter in mind, it is important
that IMGs undergo a thorough screening process to ensure that they meet the
professional standards needed to practise medicine in Australia.
The Inquiry into Registration Processes and Support for Overseas Trained
Doctors (the Inquiry) was referred to the House of Representatives Standing
Committee on Health and Ageing (the Committee) on 23 November 2010. The impetus
for the referral was a private Member’s motion proposed by The Hon Bruce Scott
MP. By way of background on 28 September 2010, Mr Scott gave notice of the
following private Member’s motion:
MR SCOTT: To move—That this House calls for:
(1) an inquiry into the role of Australia’s medical and
surgical colleges in the registration process of medical graduates and overseas
trained doctors; and
(2) the Minister for Immigration and Citizenship to delay the
revocation of 457 visas for those doctors who have been deregistered due to
failure of the Pre Employment Structured Clinical Interview, to allow adequate
time for a review of their case and reassessment of their competency.
On 18 October 2010, Mr Scott’s motion was one of the items of private
Member’s business which was debated in the Main Committee. In addition to Mr
Scott, the following Members contributed to the debate: Mr Shayne Neumann
MP; Mr Geoff Lyons MP; Mr Warren Entsch MP; Mr Bob Katter MP; Ms Jill Hall MP;
Dr Andrew Laming MP; Mr Tony Zappia MP; Mr Luke Simpkins MP; and Mr Steve
On 16 November 2010, the House of Representatives Selection Committee
identified Mr Scott’s private Member’s motion as an item of business to be
voted in the House on 25 November 2010. However, on 23 November 2010 the
Minister for Health and Ageing, The Hon Nicola Roxon MP, referred the inquiry
into registration processes and support for overseas trained doctors with the following
terms of reference:
Recognising the vital role of colleges in setting and
maintaining high standards for the registration of overseas trained doctors
(OTDs), the Committee will:
n explore current
administrative processes and accountability measures to determine if there are
ways OTDs could better understand colleges' assessment processes, appeal
mechanisms could be clarified, and the community better understand and accept
n report on the support
programs available through the Commonwealth and State and Territory
governments, professional organisations and colleges to assist OTDs to meet
registration requirements, and provide suggestions for the enhancement and
integration of these programs; and
n suggest ways to
remove impediments and promote pathways for OTDs to achieve full Australian
qualification, particularly in regional areas, without lowering the necessary
standards required by colleges and regulatory bodies.
On 25 November 2010, the anticipated vote on the motion did not proceed.
Instead the Leader of the House, The Hon Anthony Albanese MP, made the
following statement in the House:
MR ALBANESE: For the benefit of the House, I also table a
letter from the federal member for Maranoa, along the lines of the following:
Dear Minister— addressed to me as Leader of the House—
Regarding the planned vote tomorrow on my Private Member’s
Motion of 18 October 2010, I believe that the substance of the Motion has been
addressed by the Health Minister’s request for the House Standing Committee on
Health and Ageing to conduct an inquiry into Registration Processes and Support
for Overseas Trained Doctors. As such I do not believe a vote in the House is
I table the letter from Mr Scott, the member for Maranoa, for
the information of the House as to why that vote is not proceeding today.
Conduct of the inquiry
Immediately after referral on 23 November 2010, details of the inquiry
were made available on the Parliament of Australia website, and on
1 December 2010 an advertisement was placed in The Australian
calling for written submissions. The inquiry was also advertised through an
extensive mail out to interested parties, including peak bodies and
organisations, health services and hospitals and the relevant government
departments inviting submissions.
Over the course of the inquiry the Committee received 184 submissions
from organisations, government authorities and from individuals. A list of
submissions is at Appendix A. A range of publications, documents and
supplementary material tendered during the inquiry was received as exhibits. A
list of exhibits is at Appendix B. In addition a significant volume of
supplementary evidentiary material was also submitted to the inquiry. A number
of submissions from individuals, particularly IMGs who have sought
accreditation and registration in Australia, were accompanied by range of
supporting documentation (eg certificates relating to qualifications, work
history and professional training/experience, CVs, application forms and
correspondence to/from accreditation/registration authorities etc). This
material was received as additional documentary evidence. Information on this
material is at Appendix C.
In addition, the Committee undertook an extensive program of public
hearings. Twenty two public hearings, including 12 interstate public hearings
were held between February 2011 and January 2012. The Committee took verbal
evidence from a range of stakeholders including: representatives of the key
organisations responsible for various aspects of the assessment, accreditation
and registration of medical practitioners; peak bodies representing medical
practitioners; representatives of public and private healthcare facilities
seeking to meet their workforce needs; representatives of medical recruitment agencies;
representatives of government departments involved; and from individual medical
practitioners and IMGs. Details of the public hearings including a list of
witnesses, is at Appendix D.
Scope of the inquiry
The scope of the inquiry is largely defined by the terms of reference. Although
the terms of reference might be read to indicate a particular focus on the role
of specialist medical colleges in the assessment, accreditation and
registration of IMGs, a comprehensive review of these issues necessarily
requires consideration of the accreditation and registration system more
broadly. Whilst not explicit in the terms of reference, any inquiry into
accreditation and registration needs to consider linkages with other processes,
including those associated with immigration, and initiatives to encourage
medical practitioners to work in regional, rural and remote locations.
National accreditation and registration processes apply to health
practitioners intending to practise in various disciplines.
However, in accordance with the terms of reference the Committee’s
considerations are confined to issues faced by internationally educated and
trained medical practitioners.
In this context, a significant number of submissions were received from
individuals outlining personal experiences regarding accreditation and/or
registration processes. The Committee found these submissions to be valuable,
using them to form a better understanding of the issues facing IMGs seeking to
practice in Australia, and of the practical implications for IMGs and their
families. However, the Committee emphasises that it is unable to investigate
individual cases or recommend remedies for any particular person. Rather, the
aim of the inquiry is to identify systemic problems, and where possible to make
recommendations for reform to address these.
As part of the inquiry process the Committee intends to review progress
made in relation to the report’s recommendations at a later date.
Context of the inquiry
All medical practitioners, regardless of where they have qualified, must
meet certain requirements before they are permitted to practise in Australia.
As noted in the submission from the Australian Government Department of Health
These requirements are designed to ensure minimum standards
of quality and safety, and in some cases, will result in practitioners
operating under a range of conditions, including under supervision and
restrictions on area and/or scope of practice.
Medical practitioners, including IMGs, must demonstrate to the Medical
Board of Australia (MBA) that they meet these standards before they are
registered to practise. Although there is clearly a need for a robust system of
accreditation and registration with sufficient checks to ensure public safety,
some have argued that the regulatory frameworks to be navigated by IMGs are
overly complex and their administration is flawed.
Evidence to the inquiry has included various flowcharts from submitters
which have sought to show how the system operates.
However, one witness candidly described the system as resembling ‘spaghetti’.
This view was shared by some other submitters, who noted that while individual
stakeholders considered their own processes to be straightforward, once all of
these interactions were combined, the system was far more complex and
potentially confusing than it may at first appear.
For IMGs seeking to practise medicine in Australia, dealing with
accreditation and registration is often only part of the wider process. Many
IMGs, particularly those applying from overseas, need to engage with numerous
organisations to arrange for their relocation to Australia. These may include
the Australian Government Department of Immigration and Citizenship (DIAC), the
Australian Government Department of Health and Ageing (DoHA), state and
territory governments, recruitment agencies and potential employers.
Understanding and navigating multiple processes, and attempting to coordinate
disparate timeframes exacerbate the challenges faced by many IMGs.
A complex system
Prior to 2010, registration of medical practitioners was the
responsibility of medical boards in each state and territory and was
administered separately by each. In its submission to the inquiry, DoHA
informed the Committee that prior to the establishment of the National
Registration and Accreditation Scheme (NRAS) that:
... registration arrangements for health practitioners,
including the medical profession, were separately administered by state and
territory governments. This meant that requirements for registration differed
from state to state and that practitioners were required to reregister every
time they wanted to practise in another state or territory. It also enabled
some practitioners to move interstate in order to avoid scrutiny.
In late 2005, the Productivity Commission published a research report
titled Australia’s Health Workforce. The research report,
commissioned by the Council of Australian Governments (COAG), reviewed a range
of workforce issues, including:
n factors affecting the
future supply of, and demand for, health workers;
n the efficiency and
effectiveness with which the available workforce is deployed; and
n what reforms to
health workforce arrangements might be undertaken to improve access across the
community to quality and safe health care.
The report found that Australia’s health workforce arrangements were ‘extraordinarily
complex and interdependent’ and identified the following as contributing
n The Australian, State
and Territory Governments are involved in all of the key parts of the health
workforce system, and often at several levels.
n There are more than 20
bodies involved in accrediting health workforce education and training, and
over 90 registration boards.
n A host of
professional bodies administer codes of conduct which complement formal
regulation, or provide for self-regulation.
In the report, the Productivity Commission proposed an integrated and
coherent reform plan, making 20 recommendations to promote a more efficient,
effective and responsive health workforce. Key recommendations were for there
to be a single national registration board for health practitioners working in
the regulated health professions, as well as a single
national accreditation board for health professional education and training.
The National Registration and Accreditation Scheme
In July 2006, COAG agreed to establish a single national registration
scheme for health professionals and a national accreditation scheme for health
education and training. In 2008, COAG signed the
Intergovernmental Agreement for a National Registration and Accreditation
Scheme for Health Professionals (the Agreement). According to the COAG
Communiqué of 26 March 2008:
The new arrangement will help health professionals move
around the country more easily, reduce red tape, provide greater safeguards for
the public and promote a more flexible, responsive and sustainable health
The Agreement set out a plan for progressive implementation during 2010,
comprising the enactment of appropriate legislation by states and territories.
In accordance with the Agreement, Queensland took the lead with primary
legislation to implement a national scheme, enacting the Health Practitioner
Regulation National Law Act 2009 (Qld) (the National Law). During 2009
and 2010, similar bills were enacted in each state and territory, providing for
the implementation and operation of the National Registration and Accreditation
The NRAS aims to:
n improve the mobility
of the health workforce;
n stop health
professionals from having to re-register every time they cross a state border
to practice medicine; and
n save time and money
and to reduce inconvenience.
It is important to note that throughout this report, where there is
reference to provisions of the National Law, these references have been
extracted from the Queensland legislation, as it was the first state to enact
the legislation implementing the NRAS. Accordingly, these provisions may not
correlate directly with the corresponding provisions of each piece of
legislation enacted by other states and territories.
Under the National Law, a single national medical board, the MBA, is now
responsible for all matters relating to the registration of medical practitioners.
Section 35 of the National Law outlines National Board functions, which include
responsibility for setting the standards, codes and guidelines for the
profession, including the requirements relating to specialist assessment. The
Australian Health Practitioner Regulation Agency (AHPRA) was established to
provide administrative support for these functions and advice on associated
matters to the MBA (and national boards for the other nine regulated health
professions), giving effect to the NRAS.
The National Law also allows for considerable delegation of functions,
enabling the MBA/AHPRA to externalise assessment and accreditation functions.
Specifically, s 43 of the National Law enables the appointment of the
Australian Medical Council (AMC) as the independent entity responsible for the
accreditation of the medical profession in Australia. The AMC is also
responsible for managing the assessment and examination processes of the
specialist medical colleges.
As the NRAS has now been operational for almost two years, the
conclusion of the inquiry provides a timely opportunity for review.
As noted previously the complexity of the accreditation and registration
processes has been a cause of concern both for Australian trained medical
practitioners and for IMGs wishing to work in Australia. Not surprisingly
therefore, these processes have been subject to earlier inquiries.
In 2004, the Australian Competition and Consumer Commission (ACCC),
jointly with the Australian Health Workforce Officials Committee (AHWOC),
conducted a review of selection, training and accreditation arrangements of all
specialist medical colleges. The review included consideration of how these
processes applied to IMGs. The aim of the review was to:
... explore the extent to which
specialist medical colleges are operating according to the general principles
of transparency, accountability, stakeholder participation and procedural
The resulting report released in 2005 made a total of 20 recommendations
to improve college assessment and accreditation processes. In relation to
overseas trained specialists specifically, the report recommended:
n further consideration
to the recognition of prior overseas training;
opportunities for competency-based assessment and training;
n greater transparency
of college assessment criteria for overseas trained specialists; and
n improved access to
continuing professional development for overseas trained specialists working
towards specialist registration.
In 2011, almost a year after the commencement of the NRAS, the Senate
Finance and Public Administration Reference Committee inquired into its
operation and its administration through AHPRA. While acknowledging that the
implementation of the NRAS was a huge undertaking, the report noted that there
were some ‘teething’ problems associated with the transition.
The report noted that AHPRA’s poor administration of the registration
process had effected recruitment of overseas trained health practitioners.
Issues frequently raised by overseas trained practitioners seeking registration
through AHPRA processes related to prolonged timeframes, provision of
inaccurate advice and lost documentation. Concerns were also raised in relation
to English language testing and the use of specific clinical assessment tools.
The Senate Finance and Public Administration References Committee concluded
that there was scope for significant improvement in registrations processes for
overseas trained health practitioners, recommending:
n regular review of
registration processes for overseas trained practitioners; and
transparency in relation to registration timeframes for overseas trained health
practitioners through the annual publication of key performance indicators to
include data on this issue.
In an accompanying minority report, while also acknowledging that
transitional issues had led to frustration for some health professionals seeking
registration, Government Senators concluded that AHPRA was already aware of
many of the issues raised during the inquiry and that appropriate remedial
action had been undertaken. As a result Government Senators expressed the view
that the benefits of the new national registration system would become
Structure of the report
Following the introductory material and context presented in Chapter 1, Chapter
2 examines workforce issues. Specifically, Chapter 2 examines what is known about
Australia’s medical practitioner workforce and how IMGs have contributed to
meeting workforce shortages. It also considers issues associated with medical
practitioner workforce planning.
Chapter 3 reviews the current system of accreditation and registration
and the various pathways available to IMGs wishing to practise in Australia. It
also considers departments and/or agencies that IMGs may need to interact with
over and above those directly involved with accreditation and registration (eg
DIAC, DoHA, state and territory government authorities, recruitment agencies
Chapters 4 and 5 consider issues that have been raised in evidence with
regard specifically to accreditation and registration of IMGs. The focus of Chapter
4 is on the AMC’s assessment and accreditation processes for IMGs. It also
includes consideration of issues relating the role of specialist medical
colleges in assessment and accreditation of specialist IMGs. Chapter 5
considers registration processes for IMGs administered by AHPRA on behalf of
the MBA, and other processes which IMGs have to engage with in order to
practise medicine in Australia.
Chapter 6 considers system wide issues that have been raised in
evidence, primarily those associated with the transition to a national system
of accreditation and registration, an apparent lack of coordination between
agencies and the practical implications for IMGs of systemic inefficiencies.
Chapter 7 examines issues associated with access for IMGs and their
families to support mechanisms and programs across jurisdictions. The Chapter
includes consideration of access to supports for IMGs working in regional, rural
and remote areas and the implications of residency status on eligibility for