The registration and oversight of health practitioners in Australia is a complex area of regulation that covers 16 health professions and over 800 000 registered individuals.
The National Registration and Accreditation Scheme (the National Scheme) was established in 2010 by the Health Practitioner Regulation National Law (National Law), which has been adopted and applied in each of the eight Australian jurisdictions. Prior to the National Scheme, each state and territory had its own system for registering and regulating health professionals.
Under the National Scheme, health practitioners’ registration and accreditation, as well as complaints about health practitioners, are managed by the Australian Health Practitioner Regulation Agency (AHPRA) and national boards for each of the health professions. At the highest level, the National Scheme is overseen by a Ministerial Council comprising of Health Ministers from each jurisdiction.
For both health practitioners and members of the public, the National Scheme can be opaque and difficult to navigate. Although registrations are managed nationally, complaints about registered health practitioners are managed differently in Queensland and New South Wales (NSW). In addition, the operation of the National Scheme alongside other health complaints mechanisms is not well understood, and can lead to disappointment with regulatory processes and outcomes.
For AHPRA and the national boards, the task of regulating health practitioners involves an inherent tension between potential community safety risks and health practitioners’ livelihoods. This tension plays out across the range of regulatory functions, from the requirements and conditions relating to professional registrations, to the management of complaints about health practitioners (called ‘notifications’ under the National Scheme).
Over the past decade, the National Scheme has been subject to ongoing maturation and legislative reform, prompted in part by independent and parliamentary inquiries. However, as this inquiry has found, despite clear improvements, there are persistent issues with the administration of registrations and notifications. Significantly, health practitioners and notifiers continue to experience delays, disappointment, confusion and stress with regulatory processes and outcomes.
This inquiry has focused on ongoing and emerging issues experienced by health practitioners and notifiers with registrations and notifications, what has been done to address these issues by AHPRA, the national boards, and related regulatory bodies, and what more can be done to improve processes and outcomes.
Regulation of health practitioners
The regulation of registered health practitioners under the National Scheme involves a range of entities.
The registration of health practitioners across Australia is managed by AHPRA and the national boards. Notifications, however, are managed by AHPRA and the boards, except in Queensland and New South Wales, where state-based regulatory bodies have responsibility.
Overall oversight for the National Scheme rests with the Ministerial Council. The National Health Practitioner Ombudsman (NHPO) provides independent oversight of AHPRA and the national boards’ administrative processes.
Figure 1.1: Entities involved in the National Scheme
Source: AHPRA Annual Report 2019-20, p. 14.
The National Scheme only regulates individual health practitioners, and not health services themselves. Complaints about health services, fees, and unregistered health practitioners, are dealt with by health complaints entities in the states and territories.
AHPRA and the national boards
Health practitioners in the 16 regulated health professions are regulated by AHPRA and the national boards. There are 15 national boards for the 16 professions.
The boards’ role is to protect the public by accrediting courses of study, setting professional standards, registering practitioners and managing notifications about registered health practitioners.
AHPRA provides policy advice, administrative assistance and support to the boards. This includes:
developing registration standards, codes and guidelines;
publishing an online national register of practitioners;
managing registration and renewal processes for local and overseas-qualified health practitioners, and student registration;
managing notifications about the professional conduct, performance or health of registered health practitioners; and
monitoring and auditing registered health practitioners to ensure compliance with board requirements.
National Health Practitioner Ombudsman
The NHPO oversights AHPRA and the national boards. It has three main roles: complaint resolution, systemic improvement and community engagement.
The NHPO considers whether the way a matter was handled by AHPRA or the national boards was fair and reasonable, and in accordance with the relevant policies, procedures and legislative requirements. It can investigate a complaint; refer the matter to AHPRA for response; assist AHPRA to address the complaint without an investigation; or decide that the handling of the matter was reasonable and take no further action.
The NHPO is also the National Health Practitioner Privacy Commissioner. The Commissioner accepts complaints about how AHPRA and the national boards use or share personal information.
Australian Commission on Safety and Quality in Health Care
The work of the Australian Commission on Safety and Quality in Health Care (the commission) is complementary to that of AHPRA. Its role is to develop national safety and quality standards and clinical care standards, as well as to provide information and resources about safety and quality.
The commission and AHPRA meet regularly and collaborate on joint projects. Current activities include raising awareness of, and compliance with, the National Safety and Quality Health Service Standards, and raising awareness of the clinical governance responsibilities of clinicians.
For a health practitioner to practice under one of the ‘protected titles’ they must apply to register with AHPRA. There are protected titles for each profession, for example, a ‘dentist’, ‘nurse’ and ‘psychologist’. The National Law makes it an offence to use protected title, or hold yourself out to be a registered practitioner, if you are not one.
The national boards are responsible for developing registration standards, codes and guidelines outlining the requirements and expectations of registered health practitioners (including overseas-trained and qualified practitioners) and students in their respective fields of practice.
Under the National Law, registration standards must outline certain requirements, undergo extensive consultation, and be approved by the Ministerial Council, which as discussed above, comprises the Health Ministers from each jurisdiction.
Notifications are often referred to as complaints, but they are a specific type of complaint—they relate to the conduct, health and performance of registered health practitioners. They can be made by a consumer, another practitioner or an employer.
The National Law sets out the powers and functions of the national boards and AHPRA in addressing notifications. As discussed in further detail in Chapter 3, all notifications received by AHPRA must be assessed and provided to the relevant national board to consider.
The national boards have the power to intervene in matters that present an ongoing risk to public safety or that call into question a health professional’s overall fitness to practice.
A range of regulatory actions are available, including the ability for a national board to take immediate action, start an investigation, or refer a notification for further consideration by a tribunal, health panel or performance and professional standards panel.
As noted above, notifications are managed differently in NSW and Queensland. These states are referred to as the co-regulatory jurisdictions.
An overview of the differences in notifications processes between the jurisdictions is set out in Figure 1.2 below.
New South Wales
In NSW, complaints about the care, treatment, health or behaviour of a registered health practitioner are managed through a co-regulatory arrangement between the health professional councils (the state equivalents of the national boards), which are supported administratively by the Health Professional Councils Authority, and the Health Care Complaints Commission (HCCC).
The councils work with the HCCC to manage complaints, and decide which agency should deal with each complaint, with complaints about unsatisfactory professional conduct or professional misconduct referred for investigated by the HCCC. The HCCC has a wider role in complaints management covering unregistered health practitioners and health services.
The national boards have no role in handling notifications about practitioners in NSW, although AHPRA maintains a role in considering any mandatory reports and publishing decisions in the national register of practitioners.
In Queensland, the Office of the Health Ombudsman receives all notifications and concerns about practitioners, and retains only matters involving significant issues of public safety and serious professional misconduct. The other notifications are referred to AHPRA and the national boards to manage.
Previous inquiries and reviews
There have been numerous inquiries into the operation of AHPRA and the National Law.
The Senate Finance and Public Administration References Committee examined AHPRA's implementation and administration of the National Scheme in 2011. The report made 10 recommendations that reflected the complexity of the scheme, and wide-ranging early service-delivery problems.
In 2014, the Australian Health Ministers' Advisory Council commissioned an independent review of the scheme by Mr Kim Snowball (Snowball Review). The final report made 33 recommendations including recommendations specifically related to AHPRA's notifications and investigation processes.
In 2016 the Senate Community Affairs References Committee (the committee) investigated the role of the existing health complaints process in dealing with the bullying and harassment of medical students and practitioners. This included how the notifications process itself had been misused by some practitioners as a form of bullying.
During that inquiry, systemic issues about the notifications process were raised. There were concerns among practitioners that the process permitted vexatious complaints and that there were deficiencies in the way investigations were handled. This prompted the committee to recommend the establishment of a further inquiry, conducted in 2017, to examine the notifications mechanism.
The committee’s 2017 inquiry identified significant issues with AHPRA’s notifications process. Its final report made 14 recommendations aimed at improving timeliness, transparency and communication, and specifically addressing concerns about vexatious complaints, appeal rights, clinical input and the management of conflicts of interest. Many of the recommendations have been implemented, with one recommendation not supported by the Government.
In response to the Snowball Review a staged program of legislative change was agreed by all jurisdictions.
The first tranche of amendments to the National Law was made by the Health Practitioner Regulation National Law and Other Legislation Amendment Act 2017. This included improvements to the management of notifications, and amendments to the disciplinary and enforcement powers of the national boards to ‘strengthen public protection and ensure fairness for notifiers and respondents’.
In 2019 the Ministerial Council agreed on a policy which formed the basis of the second tranche of legislative amendments. The bill to enact the reforms is expected to be introduced into the Queensland Parliament (as host jurisdiction) in late 2021 or early 2022. It was noted that:
The proposed reforms include ‘increasing regulatory oversight and control of rogue and unregistered practitioners, improving the administrative operations and efficiency of the scheme [and] promoting better information-sharing between regulatory and other government agencies’.
Additional legislative amendments were also agreed, to emphasise that public protection is paramount in administering the National Scheme, and to require AHPRA to consult with patient safety bodies and consumer organisations about any changes to registration requirements.
Conduct of the inquiry
On 18 March 2021 the Senate referred the administration of registration and notifications by AHPRA and related entities under the Health Practitioner Regulation National Law for inquiry and report by 24 November 2021. On 23 November, the Senate agreed to extend the reporting date to the Friday of the first sitting week in March 2022.
The inquiry was given broad terms of reference relating to health practitioner registration and the management of notifications by AHPRA and the other health regulators.
The inquiry was advertised on the inquiry's website and the committee wrote to organisation and individuals to invite submissions by 30 April 2021. The committee continued to receive submissions after this date.
The committee received 144 submissions which are listed at Appendix 1. The majority of submissions were from individuals who provided details of their complaint with AHPRA, which the committee accepted on a confidential basis.
The committee held three public hearings in Canberra on 8 and 9 July 2021 and on 22 September 2021, as well as three in camera hearings.
Transcripts for all public hearings are available on the committee’s website, and a list of the witnesses is at Appendix 2.
Structure of this report
Following this introductory chapter, the report features three chapters which cover the following matters:
Chapter 2 examines the registration process for health practitioners and related matters;
Chapter 3 examines the administration of notifications and some of the key issues identified with the process; and
Chapter 4 discusses the impact of notifications on health practitioners.
In this report, references to Committee Hansard are to proof transcripts. Page numbers may vary between proof and official transcripts.