Chapter 5 Issues with registration and associated processes
All medical practitioners, including international medical graduates
(IMGs), must be registered with the Medical Board of Australia (MBA) to
practise medicine in Australia. Under the Health Practitioner Regulation
National Law Act 2009 (Qld) (the National Law),
the MBA was established as Australia’s national medical registration authority.
Also under the National Law, the Australian Health Practitioner Regulation
Agency (AHPRA) was established to undertake the administrative functions of the
MBA in relation to implementation of a national registration and accreditation scheme
(NRAS). The Committee’s inquiry has highlighted a range of issues relating to
poor communication and systemic inefficiencies resulting from the transition to
the NRAS. These are considered in more detail in Chapter 6.
This Chapter considers those elements of the registration requirements
that have been prominent features in evidence, and are obvious causes for
concern by many IMGs holding Limited Registration and working towards achieving
full General or Specialist Registration in Australia. Issues examined in this Chapter
n processes for
demonstrating clinical competency including concerns about:
review and supervision;
utility of the Pre-Employment Structured Clinical Interview (PESCI); and
n the process of
demonstrating English language proficiency.
While not related directly to registration, this Chapter also examines issues
relating to processes adjacent to registration which IMGs must address if they
are to be able to live and practise medicine in Australia. Issues considered
include those associated with establishing and maintaining residency status,
and restrictions on gaining access to Medicare provider benefits associated
with provisions of the Health Insurance Act 1973 (Cth).
Demonstrating clinical competency
Regardless of which registration pathway is pursued, each IMG must
undertake a period of supervised practise, in some cases with specified additional
training or requirements to pass examinations, to establish clinical competency
and gain an understanding of the Australian health care system.
The Committee took a range of evidence in relation to the processes
associated with demonstrating clinical competency from IMGs holding Limited
Registration following the Competent Authority, Standard or Specialist
Pathways. These issues related primarily to supervision/peer review and the
utility of the PESCI.
Peer review and clinical supervision
As noted above, IMGs seeking full registration in Australia undergo a
variable period of supervised practise. Clinical supervision involves the
oversight (either direct or indirect) by a clinical supervisor
of professional procedures and/or processes for the purpose of assessing
clinical competency and providing opportunities for professional development to
ensure delivery of high quality patient care. Where IMGs are seeking registration
in a specialist capacity, the term ‘peer review’ is used for this period.
Availability of clinical supervisors
Evidence suggests that it is difficult to find suitably qualified
supervisors for IMGs, particularly for IMGs working in regional, rural or
remote locations. This shortage may be heightened in the case of specialists,
where the number of potential supervisors is even more limited.
With regard to supervision, the Australian Government Department of Health and
Ageing (DoHA) notes that:
... with the ageing of the medical workforce overall, the
availability of supervisors for OTDs (as well as for Australian educated and
trained doctors) needs close monitoring, and options to ensure there is enough
supervision capacity in the system.
Also commenting on the shortage of clinical supervisors, the Rural
Doctors Workforce Agency (RDWA) observed:
There is enormous pressure for medical practitioners to
become supervisors of OTDs however there is little or no training for
supervisors. Supervisors are not paid to take on the extra responsibility.
In his submission Mr Ian Shaw, contributing in a private capacity,
Many OTDs in rural and regional areas are employed at a
private practice where, because of a practitioner shortage or high patient
ratio, no or inadequate supervision and mentoring is available.
Associate Professors Michael Steyn and Kersi Taraporewalla also noted
the shortage of supervision available to IMGs working in specialist AoN
The AoN process requires supervision by an [Australian and
New Zealand College of Anaesthesia] (ANZCA) fellow. ... AoN positions in remote
areas may not be able to provide a suitable ANZCA fellow for supervision.
Noting that IMGs are required to find their own supervised positions,
which are then subject to approval, the Royal Australasian College of Surgeons
(RACS) told the Committee:
Often the only positions available to IMGs are in hospitals
that are not traditional teaching hospitals and which have a predominant
service requirement. Often the Fellows located at these hospitals have limited
involvement in the training and education process and are not experienced in
clinical assessment processes. As they are often smaller hospitals, the IMG is
deprived of a support network of a wide range of surgical colleagues.
The Royal Australasian College of Pathologists (RACP) considered that
finding suitable placements for IMGs in remote areas is difficult:
We are very mindful of the difficulties in providing adequate
supervision in remote areas. Current workforce constraints mean that proper
supervision for peer-review pathways to [college fellowship] in remote areas is
not feasible at this stage.
Noting that in 2005 an estimated 2,669 people from the medical workforce
retired, the National Rural Health Alliance (NHRA) proposed making use of semi
or recently retired general practitioners to increase the availability of
clinical supervisors for IMGs working in regional, rural or remote locations.
To implement this, the NRHA observed:
The GPs would need to be identified and offered training and
financial support for supervision. Many of these retired professionals may
enjoy the stimulation of providing support to newly arrived doctors while
helping their local communities to access medical care. 
For IMGs intending to practise in rural or remote locations, including
those on the AoN pathway, a number of inquiry participants suggested that an
initial placement in a teaching hospital might be appropriate. One contributor
to the inquiry observed:
Areas of need are not best placed to adequately supervise
overseas trained doctors. By allowing OTDs to go directly into areas of need,
and expect the doctors in these areas to find the time to supervise them
adequately, or even at all, is ludicrous and patently unfair. They are, by
definition, in need. Most often these doctors are burned out. At best they are
extremely time-poor. Expecting them to take on supervisory roles just adds to
the load of people who are already hanging by their fingernails. It is too much
to ask, even if things go well. When things go wrong, these people are
subjected to extreme stress and are stretched to breaking point. Overseas
trained doctors should only be sent to areas of need after the 12 month
supervisory, assessment and orientation/training process is completed.
Similarly, Dr Diane Mohen told the Committee:
One measure which would help ensure that practitioners
destined to work in rural areas are well oriented to the Australian health care
system, well assessed with respect to clinical assessment, communication and
procedural skills and well supported by professional peers is to insist that
all doctors have the opportunity, and are expected, to undertake a period of
closely supervised work in a major metropolitan centre.
RACS also submitted that a period of initial supervised practise and
assessment in a teaching hospital, would better equip IMGs to work in non-urban
If appropriately funded and structured assessment posts were
created in teaching hospitals it would be preferable for IMGs to commence
assessment in these posts for approximately 6 months before rotating out to
By commencing in these posts IMGs, in conjunction with their
clinical assessors, would be able to establish their assessment plan and establish
support networks to assist them when they then move to rural and remote
While supporting the concept of initial supervised practice in a
teaching hospital, the Australian Orthopaedic Association (AOA) acknowledged
that this would have workforce implications, noting:
... supervision of OTDs in regional areas is often less than
ideal. It is for these reasons that the AOA strongly support the creation of specific positions for OTDs in the
main teaching hospitals prior to them taking up regional posts. This can put
pressure on workforce numbers in certain areas if it delays the taking up of
posts. It would however give the best form of assessment of the OTDs and allow
processes to be put in place if issues were identified.
Similarly, while acknowledging implications for addressing workforce
shortages in regional, rural and remote locations Dr Joanna Flynn of the
Medical Board of Australia (MBA) told the Committee:
Again, in an ideal situation all IMGs would do a period in a
teaching hospital for three months and be supervised before they went out any
further. They would go and work in a group setting where there were people on
site to supervise them.
The Committee understands that it may be difficult to find clinical supervisors
for IMGs for a variety of reasons. Medical workforce shortages, coupled with
workload pressures and resource constraints can impact on the capacity and
willingness of clinicians to take on supervisory roles. The Committee
recognises however that the ability of IMGs to undergo a specified period of
clinical supervision is paramount in their progression to achieving full
The need to expand Australia’s clinical supervision capacity has long
been acknowledged, and is a key component of the 2008 National Partnership
Agreement on Hospital and Health Workforce Reform.
Health Workforce Australia (HWA), under its clinical training reform program,
has provided $28 million for its Clinical Supervision Support Program (CSSP).
The intent of the CSSP is to support projects and activities aimed at expanding
clinical supervision capacity and competence. The Committee anticipates that
this process will examine a range of options to increase the supply for
clinical training places and supervision, including consideration of incentives
such as remuneration, and support for supervisor training and skills
However, with the anticipated increase in the number of Australian
trained medical graduates coming through the system, demand for clinical
supervision places is likely to increase. In this context, the Committee
believes that specific consideration should be given to the supervision needs
of IMGs, who are already struggling in some cases to find suitable clinical
supervision, and may be disadvantaged when competing for places with an expanded
cohort of Australian trained graduates.
The Committee recommends that HWA, in consultation with state and
territory health departments, the MBA, specialist medical colleges and other
key stakeholders, investigate options to ensure equitable and fair access to
clinical supervision places for IMGs. Consideration should include establishing
designated supervision placements for IMGs.
The Committee recommends that Health Workforce Australia, in
consultation with state and territory health departments, the Medical Board
of Australia, specialist medical colleges and other key stakeholders,
investigate options to ensure equitable and fair access to clinical
supervision places for international medical graduates. Consideration should
include establishing designated supervised placements for international
medical graduates in teaching hospitals or similar settings.
The Committee also believes that shortages of clinical supervisors could
be partially alleviated through the use of semi or recently retired medical practitioners
who may wish to maintain clinical currency, but who may not necessarily wish to
practise full. Options for semi or recently retired medical practitioners to provide
clinical supervision on a locum basis would allow those that may usually reside
in areas where there medical workforce shortages are not an issue, to provide
short to medium term clinical supervision for IMGs practising in regional,
rural or remote locations and there are limited number of practitioners able to
provide clinical supervision. Understandably, potential supervisors who have
retired and whose medical registration has lapsed would need to undergo some
professional development and training to ensure that their clinical skills and
expertise accords with current clinical best practice. However, the Committee
believes that the AMC, specialist medical colleges and MBA should work together
to determine an appropriate pathway to support this process.
The Committee recommends that the Australian Medical
Council, the Medical Board of Australia and specialist medical colleges
collaborate to develop a process which will allow semi or recently retired
medical practitioners and specialist practitioners to maintain a category of
registration which will enable them to work in the role of a clinical
The Committee also suggests that shortages of clinical supervisors could
be further alleviated by the innovative use of new technology to assist in the
supervisory process. The increasing availability of broadband internet services
in rural and remote locations throughout Australia should increase options to enhance
the use of new technology to better support clinical supervision for IMGs in
situations where direct access to their clinical supervisor is limited. The
Committee recommends that HWA provide support under the CSSP to promote the
innovative use of new technologies to increase clinical supervision capacity.
The Committee recommends that Health Workforce Australia
provide support under the Clinical Supervision Support Program to promote
the innovative use of new technologies to increase clinical supervision
capacity, particularly for medical practitioners who are employed in
situations where they have little or no access to direct supervision.
The Committee is particularly attuned to the difficulties associated
with providing appropriate levels of supervision for IMGs intending to practice
in regional, rural or remote locations. The Committee is concerned that many of
these IMGs are placed in vulnerable situations, often with indirect or very
limited access to their clinical supervisors, despite great levels of
responsibility. The Committee has also taken evidence to suggest that some
professional bodies do not feel that current processes for IMG clinical
assessment are adequate to demonstrate the level of clinical competency needed
to practice with this limited level of clinical supervision. The Committee is
concerned that placements without adequate clinical assessment, particularly in
cases where IMGs are the sole practitioner in a particular location, could be
seen as significantly risky in terms of safety and competency.
To address this concern the Committee believes that IMGs intending to
practise in settings with indirect or limited access to clinical supervision
should have an initial placement in a teaching hospital, base hospital or
similar setting to allow for clinical competency to be more thoroughly assessed
in the workplace prior to being assigned to a position. This not only enables a
fully registered practitioner to assess the skills and competency of an IMG
over a period of time (rather than at a brief clinical interview) and for any
perceived deficiencies to be addressed, but also allows the IMG to develop a
better understanding of the Australian health care system, Australian culture
and to develop professional and peer support networks.
The Committee concedes that this would place further demands on already
limited clinical supervision places and also would mean that some communities
would have delayed access to much needed medical services. However, the
Committee is of the view that this approach is necessary to ensure that high
standards of care are maintained in regional, rural and remote Australia.
The Committee recommends that prior to undertaking practise
in an area of need position or regional, rural, remote position with indirect
or limited access to clinical supervision, international medical graduates
(IMGs) be placed in a teaching hospital, base hospital or similar setting.
Within this setting IMGs could be provided appropriate supervision for a
defined period to further establish their clinical competency and assist with
their orientation to the Australian health care system.
Of course the Committee understands that the feasibility of this
recommendation is contingent on the availability of sufficient supervised
clinical placements for IMGs as per Recommendation 12.
Skills and training of clinical supervisors
Some evidence to the Committee suggests that prior to appointing clinical
supervisors, the MBA and specialist medical colleges should ensure that
supervisors have an additional set of skills to complement their clinical
expertise. In particular, this would include the ability to objectively assess
clinical performance, provide professional guidance and feedback and to modify
behaviour if necessary.
The Australian College of Rural and Remote Medicine (ACRRM) told the
Committee that the college:
... would support the introduction of mandatory accreditation
for all doctors supervising OTDs. Colleges should set the standards, provide
training and accreditation if there is to be improved supervision provided and
increased accountability for supervisors. Government should be providing
incentives such as support for training and accreditation of training posts and
remuneration to the supervisor for time spent in teaching and reporting.
To enhance clinical supervision of IMGs specifically, a number of
inquiry participants suggested that there is also a need for cross-cultural
awareness training. For example, Dr Wenzell
suggested that there is a need to:
Fund dedicated supervisor positions with improved training
for supervisors concentrating on cross-cultural and communication skills
Associate Professors Michael Steyn and Kersi Taraporewalla noting that ‘there
is no training of the supervisors towards assessment of cultural differences’,
Other areas of development include appropriate training for
the supervisors into assessment of behaviours and ways to modify behaviour.
Supervisors in the vocational training scheme aim to generate behaviours and
often have trouble with this element. For the OTD where behaviours have already
been established based on cultural norms in a variety of settings in their
basic training, changing to the Australian culture requires key understandings
on the part of the supervisors so as to achieve the outcome of integration,
rather than claim that the OTD is not performing as to expected. Supervisors of
the OTD also need to understand the processes and changes that the OTD has to
go through. This is not easily understood as it is difficult to find out about
the perspective of the OTD ...
The Committee believes that one way to ensure that IMGs who are required
to undergo supervision have a successful and positive experience is by pairing
them with clinical supervisors who will help them to develop and also assist in
rectifying gaps in knowledge and clinical competence. In particular, the
Committee considers that development of clinical supervisors skills in
provision of objective assessment, feedback and mentoring would be of benefit.
Although the suggestion for mandatory accreditation of clinical supervisors is
not without merit in the longer term, given the chronic shortage of clinical
supervisors at the current time, the Committee is concerned that this approach
would unnecessarily restrict access further.
As noted earlier, the Committee is aware that HWA is undertaking a range
of activities and projects to enhance Australia’s medical supervision capacity
under the CSSP. These include activities to better define the roles,
responsibilities and accountabilities of clinical supervisors, and to improve
the quality of supervision though the provision of training.
The Committee is also aware that the MBA/AHPRA also provides Guidelines for
Supervised Practise for Limited Registration. This document sets out
the principles for supervision and outlines the responsibilities of the IMG
under supervision and of the clinical supervisor.
For clinical supervisors of IMGs, the Committee understands cultural
awareness and communication may be an important contributor to effective
clinical supervision. Improved cultural awareness and communication may assist
supervisors to establish a professional relationship with their IMG, and
deliver guidance and constructive feedback on their clinical skills and
proficiency. Ideally, the clinical supervisor should also be the first person
to whom an IMG turns to for advice on clinical issues, career development,
issues of interaction with other staff and with patients. Therefore, the
Committee recommends that HWA include information on cross cultural awareness
and communication in its guidance on the roles and responsibilities of clinical
supervisors, and that these elements should be components of clinical
The Committee recommends that Health Workforce Australia
ensure aspects of cross cultural awareness and communication issues are key
components in any guidelines, educational materials or training programs that
are developed to support enhanced competency of clinical supervisors.
Pre-Employment Structured Clinical Interview (PESCI)
One of the more contentious issues raised during the inquiry was that of
the Pre-Employment Structural Clinical Interview (PESCI). For IMGs pursuing
registration via the Competent Authority or Standard Pathways, the requirements
for registration may include:
... satisfactory results of a pre-employment structured
clinical interview (PESCI) required for any non specialist position if the
Board determines the PESCI is necessary. The Board will base its decision on
the nature of the position and level of risk.
In brief, a PESCI is used to assess an IMG’s suitability for a
particular role based on the assessed risks of the particular position. It
requires the IMG to undergo a structured interview based on clinical scenarios
to demonstrate that they have the knowledge, skills and experience to work in a
particular position. The PESCI is conducted under the auspices of AMC
accredited providers by a panel of at least three members, two of whom need to be
familiar with the clinical and professional demands of the type of position
The Committee has taken evidence of the concerns held by IMGs in regards
to PESCI assessments. Primarily these concerns relate to:
n the application and
utility of PESCI, and the feedback received following assessment; and
n the consistency and
portability of PESCI across jurisdictions.
Application, utility and feedback
The submission from the Australian Doctors Trained Overseas Association
(ADTOA) listed a number of concerns regarding the PESCI based on experiences
related by 35 IMGs. These include:
n Many believed that
the PESCI exam was an inadequate, unfair and invalid measure of their clinical
skills and knowledge;
n A number complained
about the lack of fair due process with regards to the PESCI in that they were
not recorded and/or transcribed;
n A number complained
about the lack of validation of the PESCI tool ; [and]
n Some reported serious
mistakes made by the PESCI panellists. (i.e. panellists not the IMG were in
While some evidence to the inquiry reported on the limited opportunities
for IMGs to take the PESCIs and long waiting lists with delays of up to 12
months, there were more
fundamental concerns regarding the utility of the PESCI. A number of submitters
expressed frustration that some IMGs were required to undertake PESCI without fully
understanding the basis of this requirement. This seemed to be a
particular issue for a number of IMGs who have been practising in Australia for
various periods of time (sometimes for many years) under Limited Registration,
who now under the National Registration and Accreditation Scheme (NRAS) may find
that they are required to undertake a PESCI to continue practising.
With regard to using the PESCI to assess IMGs finding themselves in this
position, the Australian Medical Association (AMA) note:
While the PESCI is used for initial pre-employment assessment
of a doctor for a particular job, prior to initial registration, as an assessment
after that time it may not be the most appropriate tool to use. A PESCI test is
a pre-employment evaluation, looking at whether the applicant is able to do a
particular job. It is not a detailed performance assessment of the medical
aptitude and performance of the doctor.
The Committee also received evidence outlining concerns relating to the
subjectivity of PESCI assessments and suggesting that feedback following PESCI
is inadequate. Some IMGs were surprised to receive feedback on elements of
their performance which they were unaware would form part of the assessment. Dr
Paramban Rateesh told the Committee of his experience with the PESCI, stating:
Although it is called a structured clinical interview, it did
not have much structure to it. There were things like clinical assessment,
procedural skills, which were commented on, which cannot really be tested in an
interview. The disturbing things — people can have their opinions — that came
out of it were that I have poor communication skills. I have poor understanding
of Australian culture and idioms. I worked in a rural area for six years. I can
write a book about it. If those two aspects alone are ridiculous, the rest of
it is a sham. There was no video recording of it. I cannot go back and say, ‘I
didn’t say that’ or ‘I know what crook means’ or whatever.
Dr Rajendra Moodley strongly advocated that such assessments should be
recorded because he failed his PESCI on the basis that the assessors believed
that he had ‘poor understanding of Australian culture and idioms and poor communication’.
Dr Emil Penev noted in relating to feedback received following his
I was shocked to see that I even failed components like not
understanding the Australian culture, without being asked a single question
about it. I was marked down on not having communication skills and
understanding of Australian idioms. I was never assessed in those areas in the
SCI at all, but I was marked down!
The Australian College of Rural and Remote Medicine (ACCRM), one of the
AMC’s accredited PESCI providers advised the Committee that in terms of
Certainly, it is advertised quite broadly that we are
available to provide feedback. The feedback is recorded and a file note is made
of the areas covered in the conversation. We have had a couple of incidents
where doctors who have been unsuccessful in a PESCI, after speaking to a member
of the panel who has gone through with them at quite a personal, one-to-one
level, have developed a learning plan and got assistance.
Consistency and portability
Another issue of concern in relation to PESCI is the lack of national
consistency and recognition across jurisdictions. The fact that some
jurisdictions have differing requirements for how a PESCI is used does not
provide an IMG with certainty, particularly where an IMG needs to find
employment in another jurisdiction. For example, the Rural Doctors Workforce
Agency South Australia stated:
... in Victoria, the Royal Australian College of General
Practitioners (RACGP) Pre-Employment Structured Clinical Interview (PESCI) is
conducted against a generic job description for general practice, and then
based on the PESCI recommendations; the applicant is matched to a suitable
position. In South Australia, the RACGP requires that the applicant be assessed
against a particular position.
The General Practice Network Northern Territory also commented that the
inconsistent application of PESCI assessments causes confusion for IMGs:
It is still unclear that if a doctor passes a Pre-Employment
Structured Clinical Interview (PESCI) in one jurisdiction, it will be accepted
prima facie in another.
As noted by Rural Health Workforce Australia (RHWA):
Currently you can pass an assessment (using a Pre-Employment
Structured Clinical Interview (PESCI)) by an agency in Victoria which is
accredited by the Australian Medical Council. However, this will not be
accepted by a Medical Board in all States. How can this be when the process is
supposed to be national? This goes some way to explain why it is so difficult
to explain the national process - we don't have one!
Explaining how these inconsistencies have arisen the AMC told the
The PESCI process was developed prior to the implementation
of the national accreditation and registration scheme. Since it is designed to
assess an individual IMG for fitness to work in a designated position with
specific clinical responsibilities and levels of supervision, the assessment is
not a ‘generic’ assessment (as in the case of the AMC MCQ examination) and is
not, therefore, readily portable to another position or state. As an example an
individual IMG might be assessed through a PESCI to be suitable for
registration in an area of need position in a regional hospital, but may not
have the necessary skills or expertise to satisfy a PESCI assessment for an
area of need position in a rural or remote location.
However, the AMC proceeded to note:
The Medical Board of Australia recently initiated a review of
the PESCI process in conjunction with the Australian Medical Council, to
evaluate the effectiveness of the assessment outcomes and to explore options to
streamline the process, including the possibility of developing a more portable
or ‘generic’ assessment. The AMC is working with the MBA to conduct a workshop
on the PESCI later this year as part of this review.
The AMA also told the Committee:
We are pleased that the Medical Board of Australia has agreed
to review these in consultation with the Australian Medical Council, and we
look forward to substantial improvements from that review and this inquiry.
The excerpt below from the MBA Communiqué in August 2011, confirms that the
MBA review is considering issues associated with national consistency and
portability across jurisdictions of the PESCI:
With the transition to the National Registration and
Accreditation Scheme, there is an opportunity to review the conduct and
reporting of PESCIs to establish more consistent processes and reporting across
jurisdictions and to consider whether PESCI results are transferable across
similar risk positions. 
It is clear to the Committee that the application and utility of PESCIs
under the NRAS is a source of confusion and concern for IMGs and for some
organisations. Based on information provided by the MBA/AHPRA on standards for
IMGs seeking Limited Registration through the Competent Authority or Standard
Pathways, it is evident that MBA retains discretion as to when PESCIs are
required. However, other than the noting that the MBA will base this
determination on the ‘nature of the position and level of risk’,
there is the no further information on criteria used to make this
The Committee is also concerned by the limited information provided by
the MBA/AHPRA on more general aspects of PESCIs. While noting that this type of
information is available from some of the AMC accredited PESCI providers, the
Committee considers that the MBA/AHPRA - as the national registration body -
also has a responsibility to provide information outlining PESCI processes.
Thus information should explain how PESCIs are conducted, the nature of the
assessment and level of feedback. It is probable that the lack of readily
accessible information on the PESCI has contributed to the confusion and stress
experienced by some IMGs. In order to rectify this situation, the Committee
believes that information on the PESCI should be made readily available on the
The Committee recommends that the Medical Board of
Australia/Australian Health Practitioners Registration Agency (MBA/AHPRA)
provide more information on the Pre-Employment Structured Clinical Interview
At a minimum this information should outline:
n the criteria
used to determine the need for an IMG to undertake a PESCI assessment; and
n criteria for accreditation of PESCI providers.
n details of the PESCI assessment process including:
Þ the composition of the interview panel, the criteria used for
selecting panel members and their roles and responsibilities;
Þ the format of the interview and the aspects of skills,
knowledge and experience that will be assessed;
Þ criteria for assessment and mechanisms for receiving feedback;
Þ the process for lodging and determining an appeal against the
findings of a PESCI assessment.
This information should be easily located on the MBA/AHPRA
website and provide links to relevant information on PESCIs that is available
on the websites of Australian Medical Council accredited PESCI providers.
In addition, to alleviate concerns about the assessment process itself
and also to avoid perceptions of subjectivity in PESCI, the Committee proposes
that all such assessments be video-recorded. A copy of the video-recording
should be provided to the applicant. This will not only enable the provision of
appropriate feedback on assessments but ensure that a record is maintained
should an IMG wish to challenge the findings of a PESCI.
The Committee recommends that all Pre-Employment Structured
Clinical Interview (PESCI) assessments be video-recorded and a copy of the
video-recording be provided to the applicant for the purpose of providing
appropriate feedback on the assessment and as a record should an international
medical graduate wish to appeal the outcome of a PESCI.
While differences in PESCI processes between states and territories is
concerning in the context of a ‘national system of registration’, the situation
is exacerbated by the fact that an IMG can undertake a PESCI in one
jurisdiction and risk not having the result recognised in another, even when
relocation involves employment in a substantially similar role. Given the level
of angst expressed during the inquiry in relation to the PESCI, it is
reassuring to note that the MBA, in consultation with the AMC, is conducting a
review into the portability of PESCI assessments.
What is unclear to the Committee is what other aspects of the PESCI, if
any, will be considered as part of the review. In particular, the Committee is
keen for the MBA and AMC to include broader consideration of the utility of the
PESCI, particularly as a tool to assess the clinical competence of IMGs who
have been practising in Australia for a number of years under Limited
Registration prior to the implementation of the NRAS.
In the interests of supporting a consultative review process, the
Committee is also of the view that the MBA should provide opportunities for all
interested parties, including IMGs, to provide input. The Committee also
believes that the MBA should provide regular updates on progress of the review
and in due course provide information on the findings.
The Committee recommends that the Medical Board of
Australia, as part of its current review of the utility and portability of Pre-Employment
Structured Clinical Interview, include broader consideration of its utility
as an assessment tool, particularly its application to international medical
graduates who have already practised in Australia for a significant period of
time under Limited Registration.
The Committee recommends that the Medical Board of Australia
provide an opportunity for interested parties, including international
medical graduates, to provide input into its current review of the utility and
portability of Pre-Employment Structured Clinical Interviews.
To promote transparency, the Medical Board of Australia
should also provide regular updates on the review on its website, and at the
conclusion of the review publish its findings.
English language skills
The MBA’s English Language Skills Registration Standard (‘English
Standard’) has been the basis of much evidence during the inquiry, and has
caused difficulty for some IMGs seeking registration.
The English Standard outlines that results from either the International
English Language Testing System (IELTS) or from the Occupational English Test
(OET) are acceptable as proof that a prospective candidate for registration has
the appropriate level of English required by the MBA. The English Standard
The following tests of English
language skills are accepted by the Board for the purpose of meeting this
a) The IELTS examination
(academic module) with a minimum score of 7 in each of the four components
(listening, reading, writing and speaking); or
b) completion and an overall pass
in the OET with grades A or B only in each of the four components.
IDP Australia Pty Ltd, a company which administers IELTS, describes
IELTS Level 7 as demonstrating:
... [an] operational command of the language, though with
occasional inaccuracies, inappropriacies and misunderstandings in some
situations. Generally handles complex language well and understands detailed
The inquiry attracted a significant volume of evidence which raised
concerns relating to the English Standard. A review of the evidence indicates
that concerns about the English Standard revolve around a small number of key
n difficulties in
achieving the English Standard at the level required;
n an inappropriate
focus on academic English language skills rather than general communication;
n the limited validity
(2 years) of English language test results for the purposes of medical
Difficulty in achieving the English Standard
The Committee received evidence that suggested that some IMGs were experiencing
difficulty in achieving the English Standard at the level required by the MBA.
A number of contributors to the inquiry questioned the stringency of English
Standard, specifically the need to achieve IELTS 7 or OET level B for all four
components (listening, reading, writing and speaking) in a single sitting.
With regard to the MBA’s English Standard, Dr Viney Joshi told the
The standard of English that they are expecting from IMGs is
that of professorial English, which is absolutely crazy ... I can tell you
there will be several people — Australian trained doctors as well — who would
not be able to write one paragraph of grammatically correct, punctuated English
...Why do you expect overseas people to meet a standard which people here do
Mr Christopher Butt, a former GP with a post-graduate qualification in
Teaching English to Speakers of Other Languages observed:
There have been considerable levels of disquiet among
candidates about the Occupational English Test (OET), and in particular about
the speaking test, in which candidates are interviewed by interlocutors
untrained in any English teaching skills. The statistical hurdle of obtaining a
'B' pass in all 4 skills at the one sitting (reading, writing, speaking and
listening) is arguably unnecessarily difficult. Many candidates have sat the
test on multiple occasions, each time getting 3 'B' and one 'C' mark, and so
have to resit again and again (at a considerable cost in time and money).
The impact of difficulty in attaining the requited English Standard was
borne out by the experiences of some IMGs. For example, Dr Mohammed Anarwala,
expressed his frustration as with the English Standards noting:
I have appeared in the same OET English exam for 11 times
over the last 3 years and passed 3 skills several times but failed in 4th.
Similarly, Dr Nasir Baig indicated in his submission:
I have written the same OET English exam 19th time over the
last 3 years and passed 3 skills several times but failed in 4th.
Mr David Lamb, an English language tutor with experience in teaching
English as a second language, also made the following comment:
Candidates should not be required to pass all sub-tests
(Listening, Reading, Writing, Speaking) simultaneously. There is no evidence of
any benefit deriving from the requirement for simultaneity. Results should be
cumulative to allow candidates time to improve on areas of language weakness
(the opportunity for acquisition of language skills is more important than
The lack of feedback explaining why candidates had not achieved the
required standards was also another source of frustration for IMGs, who
reported that this restricted their capacity to rectify any identified
Academic focus of the English Standard
Some evidence suggests that while the prescribed English Standard
assessment instruments (IELTS and OET) are sufficient to assess the ability of
a candidate to read, write and comprehend English, they do not sufficiently
assess a candidate’s ability to communicate in a clinical setting. For example,
the Royal Australasia College of Surgeons (RACS) told the Committee that:
The College has previously indicated that it does not believe
this standard reflects the language skills necessary for working in the
Australian healthcare system ... 
In its submission to the inquiry, Peninsula Health emphasised the
difference between achieving the MBA’s English Standard requirements and being
able to communicate effectively in the clinical setting, noting:
It is Peninsula Health's experience that a number of OTDs
(perhaps as high as 25%) who may have passed the English examination remain unable
to practically engage with other staff and/or patients, particularly in moments
Acknowledging the influence of the diverse cultural backgrounds of IMGs
on language and communication, Associate Professor Kersi Taraporewalla told the
It is not just English; it is actual communication as such.
It is not just the words they use; it is also how they use them, what phrases,
their tone of language and what sort of background they have. There is a
difference between the level of English which the college examines them at, the
IELTS 7 that they have to perform at, and what is required as true
communication with the patient.
Asked to comment on survey results showing that 80% of IMGs do not
believe that they have communication problem, Associate Professor Taraporewalla
They may have no trouble in speaking English, but they do
have a problem addressing it to local conditions and to the local patient.
It is concerning that some IMGs, who may otherwise be competent medical
practitioners, cannot meet the English Standard. However, the Committee understands
that a standard is needed as a medical practitioner’s ability to communicate
effectively in English is a fundamental aspect of good quality and safe medical
practice in Australia.
During the inquiry the Committee took some evidence questioning the
validity and consistency of test results from the IELTS and the OET.
As the focus of this report is on issue of the English Standard as part of the
process of medical registration, the Committee is not in position to analyse information
on the IELTS or the OET as testing instruments. However, the Committee has been
reassured that both tests have already been extensively validated by linguistic
experts and accordingly the Committee does not propose to comment further on
However, the Committee believes that there is merit in reviewing the
English Standard, in particular whether the IELTS and OET levels (Level 7 and
Grade B respectively) set by the MBA are appropriate for IMGs, and whether the
need to achieve this level across all four components of testing in a single
setting is overly restrictive. While the Committee fully acknowledges the
importance of ensuring that IMGs have the requisite English language skills to
support their work in the clinical setting, at the same time it recognises that
setting unnecessarily stringent standards is not in the interest of the
The Committee recommends that the Medical Board of Australia
review whether the current English Language Skills Registration Standard is
appropriate for international medical graduates.
The review should include consideration of:
n whether the International English Language Testing System and Occupational
English Test scores required to meet the English Language Skills Registration
Standard is appropriate; and
n the basis for requiring a pass in all four components in a
Another area of concern for the Committee was that many IMGs noted the
lack of qualitative feedback available from both the IELTS and OET in cases where
they failed to achieve to required test scores under the MBA’s English
Standard. At present, the Committee understands that providers of both accepted
English language tests provide test results in the form of graded scores only.
The Committee considers that the provision of qualitative feedback would be
beneficial to IMGs to enable the rectification of any identified deficiencies.
However, the Committee understands that the MBA does not hold jurisdictional
authority over IELTS or OET test providers to mandate this type of feedback. The
Committee is also aware that IELTS and OET providers test English language
skills for a range of other health disciplines that are regulated by AHPRA which
do not incorporate a qualitative feedback component. Nonetheless, the Committee
believes that the MBA should negotiate with IELTS and OET providers with a view
to requiring that detailed, qualitative feedback on each component of the test is
provided to IMGs in writing to facilitate identification of areas of deficiency
which may be rectified.
The Committee recommends that the Medical Board of Australia
negotiate with providers of the International English Language Testing System
and Occupational English Test with a view to requiring that detailed,
qualitative written feedback on each component of the English Language test
be provided in writing to international medical graduates to enable
identification of areas of deficiency which may be rectified.
The Committee understands that communication in the health care setting
goes beyond simply demonstrating academic levels of English language
proficiency. Medical practitioners also need to fully comprehend what patients
are telling them (which will require knowledge of colloquialism and idioms),
answer questions and communicate medical information and results using language
that is readily understandable and in a manner that shows empathy for a
patient’s situation. Working in a team environment or consulting with
professional colleagues will also mean that IMGs need to be familiar with
medical and professional terminology and communication styles.
Furthermore, the cultural context of communication is crucial. For
example, in an Australian context it is not unusual for patients to want to
discuss sensitive issues, such as mental health or sexual health issues, with
their medical practitioner. It is conceivable that some IMGs may have concerns
discussing such matters with their patients. Clearly the English Standard does
not assess these aspects of an IMGs communication. Nevertheless the Committee
considers it vitally important that this aspect of communication is developed
and assessed during the IMGs period of clinical supervision. The Committee
comments further in Chapter 7 on the importance of including cultural awareness
and communication training for IMGs as an integral part of their orientation to
the Australian health care setting.
Two year validity of test results
One of the key concerns about the English Standard is that the MBA
mandates that English test results must be obtained in the two years prior to
applying for registration. The MBA may allow
exemptions to this period of validity for results if an IMG:
(a) has actively
maintained employment as a registered health practitioner using English as the
primary language of practice in a country where English is the native or first
(b) is a registered
student and has been continuously enrolled in an approved program of study.
With respect to the two-year validity of English test results, Ms Joanna
Flynn of the MBA told the Committee:
The reason that that requirement was introduced was that some
people pass their English language test and are not working in Australia or in
another English language place and are speaking their own native language and
have not spoken English since they sat the test. It is a blanket rule. I can
hear you saying that it sounds a bit harsh. The English language standards,
like all the national registration standards, are to be reviewed in the
three-year cycle. There have been some questions about whether it is the most
appropriate regime for English language testing, so there will be an evaluation
A number of submitters to the inquiry expressed concern at the two year
validity of English language test results. IMGs particularly affected by the
limited validity of English Language test results include:
n individuals whose
registration has lapsed, requiring them to reapply for Limited Registration and
repeat their English language test if existing results are more than 2 years
n IMGs who have been
practising for varying periods of time in Australia transitioning from state
based registration systems to the NRAS; and
n individuals who experienced
delays in applying for Limited Registration during which time their English
language test results expire.
The impact of the two year validity for English test results is
illustrated by Dr Anarwala. Dr Anarwala successfully completed the AMC 2-part
assessment, and was asked to undertake another English language test as results
from an earlier test were more than two years old. Despite repeated attempts Dr
Anarwala has not been successful in attaining the OET English Standard required
by the MBA. Dr Anarwala told the Committee:
After [previously] passing the English proficiency
examination, I remained in Australia since. I do not think that the level of my
English skills has lowered. I believe that the validity of English proficiency
for two years is totally wrong especially if a medical professional remains in
English speaking country.
Dr Sayed Hashemi also related his experience regarding English language
testing as follows:
As of July 1st 2007, the
NSW Medical Board required overseas trained doctors to pass the OET before
progressing onto the AMC Clinical and MCQ examinations. Also, the OET would not
be considered if it was
achieved more than two years at the time of applying for placement. This is
where I was severely disadvantaged as it meant that my OET success was now
'expired'. I had completed all exams in March 2007, before the change in policy
I am an Australian citizen who has lived in Australia for
several years (i.e. 19 years). Inevitably, living here I have adopted the Australian
culture, interact daily with English speaking community and taking in English
media. ... I believe my language skills, understanding and appreciation for the
Australian culture and have deepened rather than gone backwards or 'expired'.
Dr Salahuddin Chowdhury related his experience of being required to
resit the English language test despite having passed previously in 2003 and
again in 2006. Dr Chowdhury told the Committee:
They have asked me to do English again. But I was
continuously working as a general practitioner and, according to the website,
those doctors who have worked continuously in general practice in Australia or
anywhere in Australia are not required to do English again.
Another IMG, expressed his frustration at the two year validity of the
English language test results, noting despite having lived and worked in
Australia since 2005, under the NRAS he had been required to repeatedly
undertake English language testing.
Also commenting on the period of validity for English language test
results, Mr Lamb told the Committee:
Any limitation to the validity period of an English Test
should be related to the period it would take to complete the entire
registration process. The validity period should not be used if applicants are
hindered by non-availability of Medical Tests (for example, MCQ, Clinical).
There may be valid reasons for applying a limited validity period to language
test results obtained outside Australia, but there is no evidence of much
deterioration of language skills in people who are living and working in
Australia. Any skill that is not used can become blunted, and this applies
equally to Australian-educated people.
When asked by the Committee to comment about the two year validity, Mr
Gerrard Neve of the OET Centre responded:
... there is a significant body of research into the area of
second language acquisition or language loss, more specifically known as
attrition, that suggests that the two-year period is quite conservative.
Noting further that the MBA’s English Standards require candidates to
attain a high level of English language proficiency, Mr Neve added:
There is a body of research that suggests that for candidates
who have already demonstrated a performance at the higher end of that spectrum
two years is very conservative and that we might be looking at something like
four years as perhaps an appropriate period before we can start to confidently
suggest that any language loss could occur.
The Committee understands the importance of establishing English
language standards to ensure that IMGs can demonstrate competent English
language skills, and that the requisite level of competency is current.
However, it is evident that the restricted validity period for English language
test results is a source of frustration. This was particularly so for IMGs who,
as a result of the transition to the NRAS find that they are required to
undertake English language testing as earlier test results have expired. This
appears to be the case even for some IMGs who ostensibly qualify for exemption
from this requirement based on the fact that they have been continuously working
in medical practice in Australia.
While the Committee understands the need to ensure the currency of
English language skills, the English Standards should not impose an
unreasonable burden on IMGs. In terms of finding an appropriate balance, the
Committee considers that the two year period of validity for English language
proficiency results is unreasonably short. Noting the four year period allowed
for renewal of Limited Registration under the NRAS, and in view of evidence
about second language attrition over time, the Committee recommends that the
MBA extend the period of validity for English language proficiency test results
as prescribed by the English Language Skills Registration Standard to a period
of four years.
The Committee recommends that the Medical Board of Australia
extend the period of validity for English language proficiency test results
as prescribed by the English Language Skills Registration Standard to a
minimum period of four years.
Processes adjacent to registration
In addition to complying with the requirements of the NRAS, IMGs are
required to interact with a range of other organisations and agencies in order
to remain in Australia and practise as the work toward either General or
Specialist Registration. These include:
n the Australian
Government Department of Immigration and Citizenship (DIAC); and
n the Australian
Government Department of Health and Ageing (DoHA) and Medicare Australia.
The remainder of this Chapter will examine the interrelationship between
immigration, residency and registration. It will also examine issues related to
visa and residency status and the implications for accessing Medicare provider
Immigration and registration
Once an IMG (and their family) have made the decision to come to Australia
with the intention of practising medicine, contact must be made with DIAC to
determine the individual or family’s immigration status. Broadly, there are two
paths that can be followed; that by a temporary resident and that by a
The inquiry identified a number of issues affecting IMGs which relate to
their interactions with DIAC or to their immigration status. These issues
include the provision of registration information for the MBA/AHPRA to assist DIAC
to make timely decisions in relation to granting of visas, the impact of changes
to immigration status from temporary to permanent residency and deregistration
of temporary resident IMGs, all of which are discussed below. Other issues
relating to immigration status and access to various support for IMGs and their
families are addressed in Chapter 7.
Provision of data for immigration decision making
Once an IMG is offered employment, the IMG must contact the MBA to apply
for registration. At around the same time, IMGs who do not already have
residency in Australia will need to commence the process of obtaining a
suitable visa from DIAC. For the majority of IMGs this means applying for a Temporary
Business (Long Stay) Visa (the 457 visa). Once an application has been lodged, DIAC
assesses the applicant for visa eligibility based on a range of eligibility
criteria. This assessment requires DIAC to obtain some information on the
applicant’s registration status from the MBA.
As explained by Mr Kruno Kukoc from the Migration and Visa Policy
Division of DIAC:
We do rely on the MBA to provide that registration and to
provide the information to the visa applicant, who then brings this as part of
the skills assessment criteria under the visa application process.
DIAC further advised in its submission:
At present, the outcome and process for the registration of
OTDs is not easily accessible for departmental case officers making decisions
on visa applications. The provision of reliable registration information in
this area would result in a streamlining of the registration and immigration
skills assessment processes, ensuring that OTDs are not inadvertently delayed
by communication difficulties between government and professional bodies.
In seeking to improve this circumstance, Mr Kukoc explained to the
Committee how access to the MBA/AHPRA registration database would assist in
streamlining the immigration decision-making process, noting:
With some other bodies ... we are able to interrogate the
registration database of that body and that streamlines the process a lot. We
believe that if MBA would consider such a proposal that would probably
streamline the visa application process as we would be able to identify
immediately and get the information off the registration database to support
the visa application.
The inquiry has highlighted that there are processes which exist in the
system of accreditation and registration that contribute to the inefficiencies
and delays effecting IMGs. The Committee notes that one of the significant
frustrations experienced by many IMGs relates to the complexity of the whole
process of coming to Australia and seeking registration to practice medicine.
IMGs who are dealing concurrently with multiple different entities have told
the Committee that they are required to provide the same information time and
time again to confirm that they meet the criteria of each separate entity. Poor
communication between entities involved in immigration, registration and
employment contributes to the levels of frustration that IMGs experience.
The Committee believes that streamlining communication between the
MBA/AHPRA and DIAC would alleviate some of the concerns expressed by IMGs and
those seeking to recruit them. Specifically, the Committee recommends that the
MBA/ AHPRA should provide DIAC with access to the information on its
registration database to expedite DIAC’s decision making process on visa
eligibility. Importantly, for privacy reasons, the accessible information
should be limited to that information that would be necessary for the granting
of a visa for employment purposes.
The Committee recommends that the Medical Board of
Australia/Australian Health Practitioners Registration Agency provide the Australian
Government Department of Immigration and Citizenship with direct access to
information on its registration database as necessary to determine granting
of a visa for employment purposes.
In Chapter 6 of the report the Committee deals extensively with issues
relating to systemic inefficiencies. One of the key recommendations relates to
establishing a central document repository. If a central document repository is
established, the Committee anticipates that DIAC could be granted an
appropriate level of access in order to obtain the information it requires.
Deregistration of temporary resident international medical graduates
As noted above, temporary resident IMGs (typically holding 457 visas)
make up a high proportion of IMGs in Australia. As a result, losing
registration can lead to a range of difficulties for IMGs. In particular,
holders of 457 visa risk deportation from Australia upon deregistration. As Mr
Michael Willard of DIAC’s Migration and Visa Policy Division told the
What typically will happen is that the doctor's employer will
inform us that the doctor is no longer registered, and then we need to take
cancellation action. That involves a letter that is called a Notice of
Intention to Cancel that goes to the doctor. And that asks them to do one of
three things: to make an application for another visa, to make arrangements to
depart Australia, or to talk to us about their circumstances.
The Committee took evidence from a range of IMGs who outlined their
circumstances with respect to their experiences of being deregistered and being
faced with deportation. In these circumstances,
457 visa conditions stipulated that IMGs have 28 days to try and reregister,
find another sponsor or to leave the country. The potential impact of this on IMGs
and their families is illustrated by Dr Rajendra Moodley who told the
... [you are given] 28 days to leave the country, whether you
own an asset, you own a home, you have a car, you have children in school — no concept
of how it is going to affect them. ... I did not know what I was going to do — put
a shirt on and leave, tell my friends to take my keys, sell my house, tell my
children, ‘You cannot go to school now.’
In circumstances where an IMG is in the process of appealing an MBA
registration decision, Mr Willard advised the Committee that DIAC had
discretion to extend the 28 day period if appropriate, or to offer a bridging
visa. However, Mr Kukoc
We have some discretionary powers. ... The 457 visas are
temporary visas. As such, the holders do not have access to any social
security, community support or general government support. If that person is
not able to practise in the occupation in which they work, there are legitimate
questions about how that person will be self-supported in Australia. That is
also an important question to be asked. Other avenues are available to that
person. A person can go back to his home country. When the appeal process kicks
in and the appeal hearing is set, we consider other visa options such as 456
[Business Short Stay] to facilitate that person appealing.
The Committee understands that once a temporary resident IMG on a 457
visa ceases to hold registration with the MBA, they will receive a Notice of
Intention to Cancel, leaving them 28 days to investigate other options or leave
the country. Given these circumstances, it is easy to see how IMGs, some of
whom may have resided in Australia for a considerable period of time, may find
it difficult to finalise all aspects of their lives in Australia within that
short timeframe prior to departing. Clearly this is likely to be stressful and
disruptive for IMGs and their families.
Notwithstanding this, the Committee understands that the 28 day period
associated with the Notice of Intention to Cancel is a condition of the 457
visa, which applies to all holders of this visa class regardless of their
profession. As this visa class requires the holder to be employer sponsored, an
IMG who does not hold registration and so is unable to practise, cannot comply
with the visa conditions. Individuals on this visa type should be fully aware
of the visa conditions.
While the Committee understands that the 28 day period is a condition of
being granted such a visa, it also appreciates
that DIAC has some discretion to extend that period depending on individual
circumstances. While recognising that this discretion is applied on a case by
case basis, the Committee urges DIAC to give due consideration to IMGs who
cease to hold registration and who are in the process of appealing an MBA
decision regarding registration.
Classifying areas of workforce shortage
There are two systems operating to identify areas of medical
practitioner workforce shortages in Australia, the so called Districts of
Workforce Shortage (DWS) and Areas of Need (AoN).
DWS is a Commonwealth Government tool, administered by DoHA, which
estimates population based doctor-to-patient ratios. Where ratios indicate that
there is an insufficient number of medical practitioners in a geographical
location to service a population, the location is assigned a DWS
classification. AoN classifications are determined by state governments and are
linked to particular job vacancies for medical practitioners which have been
vacant for some time, despite attempts to fill the positions. The criteria used
to determine AoN status vary between jurisdictions.
The operation of DWS is linked to provisions in the Health Insurance
Act 1973, specifically s 19AB of the Act. As explained by DoHA, the
... restricts access to Medicare benefits and generally
requires OTDs to work in a district of workforce shortage (DWS) for a minimum
period of 10 years from the date of their first medical registration in
Australia in order the access the Medicare benefits arrangements.
This restriction is commonly known as the 10 year moratorium. The 10
year period can be reduced by up to five years if IMGs work in eligible
regional, rural and remote areas as defined by the Australian Standard
Geographical Classification – Remoteness Areas (ASGC-RA).
AoN classifications operate by providing IMGs with opportunities to
access an accelerated accreditation and registration pathway (Specialist AoN
Pathway) if they agree to work in a state government approved AoN position or
The inquiry received a significant volume of evidence raising concerns
about the DWS and AoN classifications, and their application. The main issues
that have emerged relate to:
n confusion associated
with DWS and AoN classifications; and
n the equity and
utility of the 10 year moratorium.
Districts of Workforce Shortage (DWS) and Areas of Need (AoN)
Although broadly speaking DWS and AoN are intended to address issues of
medical practitioner workforce shortage and mal-distribution, in a
supplementary submission to the inquiry, DoHA provided the following
clarification regarding their implementation:
The DWS and Area of Need (AoN) systems have been established
for different purposes.
DWS is a workforce distribution mechanism that is based on
the Medicare billing statistics and applies to overseas trained doctors (OTDs)
and foreign graduates of accredited medical schools (FGAMS) who are seeking to
access the Medicare benefits arrangements for their professional medical
The AoN system has been implemented to fill vacant medical
positions, in both the public and private health systems, with conditionally
registered medical practitioners, both Australian and overseas trained.
The Committee took a range of evidence which suggested dissatisfaction,
confusion and frustration with the application of the two classification
systems. The National Rural Health Alliance (NHRA) dealt at length with
concerns around the way in which DWS is estimated. The NHRA specifically noted
a lack of transparency associated with the way in which DWS is determined and
frequent review and changes in DWS status, making it difficult for health
service providers to effectively plan recruitment strategies.
Advocating for more transparency, the NHRA commented further:
Improved transparency of the way in which calculations are
made would help GP practices and health services to prepare applications for
DWS status and, more importantly, to anticipate which factors may result in a
change of their status in the future. If these factors were known, they may be
better able to prevent loss of their DWS status or to implement alternative
The NHRA suggested that the DWS classification should be replaced by ASGC-RAs,
It would be a significant improvement if decisions relating
to DWS and AON were based on the same boundaries as apply for rural relocation
incentives: ASGC-RA 2-5. At present there are different boundaries for different
rural and remote workforce mechanisms and this adds to the complexity of the
system. Most importantly, boundaries based on AGSC RA would be more predictable
and would change less frequently.
A number of contributors to the inquiry expressed a range of concerns
relating to AoN classified positions. For example, in a joint submission Associate
Professors Steyn and Taraporewalla identified the following problem with AoN:
There is confusion as to what the result of the AoN process
signifies to the applicant. If the applicant is considered as approved for the
position, the process accepts them as suitable to work in a specialist capacity
but denies them recognition as a specialist. This is anomalous, has no real
function and perhaps constitutes abuse of the [overseas trained anaesthetist].
Confusion about the outcomes of the AoN process is well illustrated in
the submission received from a South African trained ophthalmologist who
I somehow had the impression that the hospital would sponsor
my residency after 2 years of work and did not quite understand that my
professional application for AoN and Specialist recognition was different - I
thought my application documents were being sent to the same processing bodies
- AMC, COLLEGE, MBQ etc.
Also commenting on the utility of AoN positions, Dr Diane Mohen, a
consultant obstetrician and gynaecologist submitted:
AON positions were created to allow health services to fill
gaps to which local graduates cannot be recruited. In reality they have created
a level of second tier specialist services and which have allowed health
services to avoid the issue of ensuring that the support, incentive and working
conditions that should be provided to attract locally trained specialists. AON
positions also create situations where OTDs can avoid pursuing the requirements
and attaining the skill set and knowledge needed to meet permanent registration
to work as a specialist in the Australian workforce.
Some submitters have called for the AoN pathway to be discontinued to
encourage IMGs who are specialists to seek full recognition through the
Specialist Registration pathway.
In addition, some contributors to the inquiry commented on the interaction
between DWS and AoN. Noting that many IMGs subject to s 19AB restrictions
requiring them to work in a DWS to access Medicare provider benefits, will also
work in an AoN position, the NHRA submitted:
There appears to be duplication in these processes and it is
unclear why both processes are required when either an AON or DWS
classification should suffice to confirm that there is a workforce shortage.
Confirming that an overlap between DWS and AoN classification exists,
While there are no formal arrangements, the AoN units within
each state and territory generally require that a vacant private practice
position is located within a DWS area for the relevant specialty prior to
granting an applicant employer approval to employ an AoN doctor.
The submission from the Association of Medical Recruiters of Australia
and New Zealand made the following observation on the links between DWS and
Most States now insist on the DWS being part of the AON
application process. Oddly enough we have gone for a standard nationwide
registration process but still have the situation where every State/Territory
determines its specific AON allocations and requirements. The system needs to
be changed to improve transparency and to allow for a site with DWS to
automatically be allocated AON status.
As a major recruiter of IMGs, Mr Kevin Gillespie of Health Link Family
Medical Centres expressed his frustration with the DWS and AoN classifications,
An IMG GP requires an Area of Need (AoN) certificate from the
State Government Department of Health and a District of Workforce Shortage
(DWS) approval from the Federal Government Department of Health and Ageing.
These 2 approvals both aim to ensure that an IMG GP is only recruited and
registered to work in an area of GP workforce shortage. This could be
streamlined and improved by only requiring 1 approval, simplifying and
shortening the registration process but still maintaining integrity.
The Committee recognises that tools to identify locations where there
are current shortages of medical practitioners, monitor changes in service
needs and workforce distribution over time, are needed to assist with workforce
planning and the implementation of measures to address workforce shortages. In
relation to DWS, the Committee notes evidence questioning the validity of the
criteria and methodology used in its determination. While acknowledging these
concerns, the Committee makes no further comment here, as it later
consideration on longer term utility of the 10 year moratorium may make comment
on the DWS at this stage redundant.
However, given the current importance of DWS classification to
recruitment of IMGs (ie enabling IMGs to qualify for a Medicare provider
number), the Committee is of the view that the process for determining DWS
should at least be made fully transparent. This will assist health recruitment
agencies, GP practices and health services, as well as IMGs and community
members, to better understand and engage with this classification system.
The Committee recommends that the Australian Government
Department of Health and Ageing produce and publish on its website a
comprehensive guide detailing how District of Workforce Shortage (DWS) status
is determined and how it operates to address issues of medical practitioner
workforce shortages. The guide should include detailed information on the
n the methodology of DWS determination;
n frequency of DWS status review; and
n criteria for benchmarking of appropriate workforce levels.
The Committee also notes evidence it received in relation to AoN
classifications and registration processes. Although the Committee understands
that there are jurisdictional variations for determining AoN positions,
concerns seemed to relate to the AoN registration pathway, rather than to the
use of the AoN classification itself. The Committee was particularly concerned
to note that some IMGs were unaware the AoN appointments do not automatically
lead to full Australian medical registration. Clearly, it is important that
IMGs are made aware of the limitations associated with AoN positions, and the
need for them to pursue other registration pathways if they wish to achieve
General or Specialist Registration.
At the same time, the Committee is aware that prior to the
implementation of the NRAS some IMGs were able to practise for many years in
Australia without progressing to full registration. Now with restrictions on
renewals of Limited Registration under the National Law (one year, plus three
renewals), there is more impetus for IMGs to progress to General or Specialist
Registration. In view of this, the Committee does not believe that there is
sufficient justification to recommend that the AoN pathway be discontinued, as
it will still facilitate recruitment of IMGs to positions that are vacant and
which have not been able to recruit suitable Australian trained medical practitioners.
With regard to DWS and AoN, it is understandable that some confusion
occurs as a result of the presence of two systems of classification of
workforce need. On some occasions during the inquiry the Committee was aware
that the terms AoN and DWS were used incorrectly in the context of discussion,
or where the terms were used loosely, as if interchangeable.
The Committee believes a nationally consistent and transparent approach
to determining AoN based on agreed criteria is appropriate in the context of a
national registration scheme. Furthermore, while acknowledging that AoN and DWS
support two distinct mechanisms of addressing medical workforce shortages, the
Committee believes that in establishing a national approach to determining AoN
there is scope to improve alignment between AoN and DWS. At present, even
though some jurisdictions only provide AoN status for positions that are
located in a DWS, the Committee understands that IMGs working in AoN positions
are required to obtain two separate sets of documents, one from the relevant
state or territory government confirming AoN status and another from DoHA
confirming DWS. The Committee considers that a nationally consistent and
transparent approach to determining AoN status and improved alignment between
AoN and DWS would reduce confusion and streamline administrative processes for
IMGs working in AoN positions.
||The Committee recommends that the Australian Government
Department of Health and Ageing consult with state and territory government
departments of health to agree on nationally consistent and transparent
approach to determining Area of Need (AoN) status based on agreed criteria.
Consideration should also be given to improving the alignment between the AoN
and Districts of Workforce Shortage.
Utility of the 10 year moratorium
One of the most controversial aspects of the medical registration system
relates to the 10 year moratorium and the operation of s 19AB of the Health
Insurance Act 1973 (the Act). As noted earlier, the aim of the 10 year
moratorium is to ensure distribution of medical practitioners to areas where
there are shortages, including outer-metropolitan, regional, rural and remote
locations in Australia.
While this aim is admirable, the Committee took evidence from
individuals, organisations and agencies suggesting that the 10 year moratorium
may be ineffective and even discriminatory. Specifically, several submissions
to the Committee identified that the 10 year moratorium was unfairly preventing
IMGs from seeking employment outside of DWS, limiting career progression, limiting
access to support and development opportunities, as well as impacting on
families. For example, the Rural
Doctors Association of Australia (RDAA) told the Committee that:
In RDAA's view, the 10-year moratorium is discriminatory and
imposes immense hardship on OTDs and their families. If there is to be a rural
service obligation attached to the allocation of Medicare provider numbers,
this service obligation should apply to all doctors wishing to practise in
Australia, not just those who trained overseas.
Similarly in its submission, headspace, Australia's National Youth
Mental Health Foundation, contended:
The 10 year moratorium, which requires OTDs to work
exclusively in rural and remote areas for 10 years or more, has been accused of
being used to ‘prop up the rural and remote medical workforce’. The 10 year moratorium is viewed by many as
being discriminatory and potentially harmful to both to the OTD and patient as
it often places OTDs in areas where there is limited or no access to
professional support or supervision in what has been described as some of the
most professionally challenging clinical environments.
Dr Andrew Pesce, President of the AMA told the Committee:
... that the best way to support ... IMGs ... is to work
towards removing the 10-year moratorium brought about by s 19AB of Health
Insurance Act. It is now formal AMA policy that the moratorium be removed.
We know that that cannot happen overnight, but the sooner we make a decision
that we should not rely on the moratorium to provide ourselves with a
workforce, the sooner we will make long-term decisions that are necessary to
address workforce problems, without using, I guess, a conscription model.
The AMA questioned the longer term utility of the 10 year
moratorium noting the anticipated increase in Australian trained medical graduates.
The AMA made the following suggestion:
Now that we have had a big increase in the number of
graduates from Australian medical schools and the number is working its way
through to a peak in graduations in the year 2014, it is time to phase out the
moratorium requirements as we phase in the new graduates.
The Melbourne Medical Deputising Service also recommended scaling back
the period of the 10 year moratorium and phasing out its application to IMGs
with permanent residency status.
Conversely, the Committee took other evidence which suggested a
continuing need for the 10 year moratorium to ensure that the medical staffing
needs of outer- metropolitan, regional, rural and remote Australia are met.
For example, the submission from Tropical Medical Training (TMT) states:
It is with concern that TMT acknowledges the call by the AMA
and RACGP to dispense with the 10 year Moratorium without advocating any method
of ensuring regional communities in outback regions gain the medical services
Dispensing with the 10 year moratorium would be especially
difficult for rural and remote areas of Australia who rely on OTDs to fill over
40 per cent of their workforce. This reliance will remain for many years due to
the hardships and deprivations faced by the remote areas of Australia.
In its submission to the inquiry, the Rural Doctors Network (RDN) outlined
its support for retaining the 10 year moratorium as follows:
RDN is in favour of the retention of the Ten Year Moratorium.
Without it there would be an even more desperate shortage of doctors in rural
areas. RDN does not see the Moratorium as an alternative to massive extra
support for rural health needed to attract Australian graduate health
professionals to rural and remote areas, but acknowledges that without the
Moratorium the existing shortages would be much worse.
In a supplementary submission to the inquiry, the Rural Health Workforce
Agency (RHWA) further emphasised its support for the continuation of the 10
year moratorium contending that:
n the IMG recruitment
strategy, and by implication the 10 year moratorium, had been successful in
increasing the number of general practitioners practising in rural Australia;
n compulsory rural
service schemes, such as the 10 year moratorium, are a practical necessity in
the absence of better alternatives.
The inquiry also received some evidence related to s19AA of the Act and
its interaction with s 19AB. In brief, s 19AA of the Act does not allow access
to Medicare benefits for medical practitioners (Australian trained or IMGs) who
are permanent residents or citizens unless they are Fellows of a specialist
college or are doing an approved postgraduate training or workforce placement.
As a result, IMGs with permanent residency status may under some
circumstances find that they are constrained by the requirements of both s 19AA
and s 19AB. As Dr Susan Douglas told the Committee, after gaining her permanent
residency, although she was still registered with the MBA in effect could not
practise as s 19AA restrictions now also precluded her from accessing a
Medicare provider number. Dr Douglas observed:
I was stunned! I had purposefully investigated whether
becoming a permanent resident would affect my ability to practice! The devil
was in the detail in that in theory I was still registered - I just couldn't
practice because I didn't have a provider number.
Mr Hugh Ford, an ACT based solicitor also outlined circumstances affecting
an IMG client who on becoming a permanent resident, found that the provisions
of s 19AA and s 19AB restricted his options to practise to a greater degree
than when he had temporary residency status. Commenting on this
issue generally, the NHRA observed:
OTDs who are citizens or permanent residents should not have
more restrictions on their ability to practise than those who are not or not
yet citizens of Australia.
The Committee notes that the inquiry attracted a significant volume of
evidence relating to the issue of the 10 year moratorium. From that
evidence it is clear that there are dichotomous views on the use of 10 year
moratorium as a mechanism to address medical workforce shortages, and its
longer term retention or revocation. Although the Committee is conscious of
very strong objections to the 10 year moratorium on the basis that it is
discriminatory and inappropriate, the Committee does not believe that the
immediate repeal of s 19AB of the Act is a responsible course of action. This
is particularly as according to some inquiry participants its removal could
come at the detriment of the many regional, rural and remote communities that
rely on IMGs to fill their medical workforce needs.
As Australia moves towards the goal of self-sufficiency for its medical
practitioner workforce, the Committee understands that the utility of s 19AB as
a tool to influence workforce distribution is likely to diminish in conjunction
with a reduced reliance on IMGs to address workforce shortages. In view of
this, the Committee supports a carefully planned, scaled reduction in the
length of the 10 year moratorium would be an appropriate course of action. The
Committee considers that an equitable arrangement would involve a scaling back
the 10 year moratorium so that it is consistent with the average duration of
return of service obligations that apply to Australian graduates of Bonded
Medical Places. To initiate this
process, the Committee recommends that DoHA, in association with Health Workforce
Australia (HWA), assess options for a scaled reduction in the length of the 10
year moratorium and use workforce modelling to determine the implications for
workforce preparation, transition, training and distribution.
||The Committee recommends that the Department of Health and
Ageing, in association with Health Workforce Australia, examine options for a
planned, scaled reduction in the length of the 10 year moratorium so that it
is consistent with the average duration of return of service obligations that
apply to Australian graduates of Bonded Medical Places. Workforce modelling should
be used to determine the implications for workforce preparation, transition,
training and distribution. The outcomes should be made publicly available.
Notwithstanding the Committee’s comments and recommendation, it is
important that IMGs currently affected by s 19AA and/or s 19AB of the Act have
access to clear and comprehensive information on the application and operation
of these provisions. The Committee considers that additional information and
guidance could be provided by DoHA through an enhanced DoctorConnect website and
through associated supports. The Committee comments further on this proposal in
Chapter 7 of the report.
Importantly, as Australia moves towards self-sufficiency for its medical
practitioner workforce, the Committee anticipates that more measures will be
needed to encourage Australian trained medical practitioners to work in areas
where there are workforce shortages. The Committee understands this issue is
being considered as part of HWA’s Rural and Remote Health Workforce Innovation
and Reform Strategy.