Effect of implementation difficulties on health practitioners
This chapter details the practical effects of the difficulties that
health practitioners, patients and service providers experienced in dealing with
the Australian Health Practitioner Regulation Agency (AHPRA) since it took over
registration on 1 July 2010. These difficulties were experienced by all 10
of the health professions regulated under the National Law and resulted in
concerns about financial and legal implications, impact on resourcing of the
health workforce, provision of health services, and access to Medicare and
other health claims. In addition, the effects on individual practitioners were
substantial and ranged from anxiety and emotional distress to loss of income
and in some cases loss of employment opportunities.
The effects of the implementation difficulties of the National
Registration and Accreditation Scheme (NRAS) were not limited to health
practitioners: the committee received evidence from large health providers and
from organisations in rural areas which clearly identified that access to
health services had been compromised during the implementation period. CRANAplus
The impact on the individual practitioner as a result of the
inefficient delivery of process has a cascading effect on the health service
they work for and then potentially consumers of that service...Ultimately, the
discovery that staff are not registered, with the resultant legal implications
of that, the impact is felt by the service providers, particularly in the
remote context where they have a very limited workforce pool. This then impacts
on consumers when the health service is unavailable due to an unregistered
The Australian Medical Association (AMA) provided the following comment on
the considerable problems experienced with the registration system:
The cost shift is to the professions, the burden shift is to
the professions, the anxiety shift is to the professions and it does not take
much to work out how people have lost confidence.
The problems caused by the issues with the registration process, and the
resulting implications, were acknowledged by the Australian Health Workforce
Ministerial Council (AHWMC):
Some delays in registration have had an impact upon
practitioners and heath [sic] services. In some instances the time taken to
process registration applications, particularly for overseas applicants, has
resulted in delays in the commencement of employment for and for others has
delayed the establishment of private practice. Some patients have also had
appointments cancelled or rescheduled.
The committee heard that the impact of the issues experienced under the
registration system were immediate and wide ranging. Witnesses explained to the
committee that the effects of the registration process became apparent from
July 2010, as soon as registration fell due:
This started mid last year, with great concern from members
about the length of time in accessing the medical board to find out if they
were registered or not, and the problem snowballed from there.
Not all organisations were aware of the problems at the same time. The
Australian Physiotherapy Association (APA) for example, commented that it
became aware of the issues with the registration process in early January 2011.
Quantifying the impact
The issues arising from AHPRA's administration of the registration
system affected large numbers of practitioners from across a range of
professions. Witnesses quantified the number of their members impacted by the
registration difficulties for the committee, as follows:
Royal Australian College of General Practitioners (RACGP): over
100 members contacted the RACGP following the difficulties they were having
with their registration and the problems they encountered in contacting AHPRA,
and an estimated several hundred of their members were not informed of their
MDA National Insurance: 15‑20 of their members approached
them directly about registration issues;
Australian Dental Association (ADA): over 500 members experienced
difficulties communicating with AHPRA to check the status of their
registration, and members who were sent the wrong information about their
registration, even though they had put in paperwork and paid fees, numbered 'in
Ramsay Health Care Australia: 234 employees (207 nurses and
midwives, 25 allied health staff and 2 medical practitioners) were unsure
if they were able to practice, as although they had submitted their
registration, their names did not appear on AHPRA's register, and 34 of these
employees (all nurses) had to cease practice for a period of between 3 days to
5 weeks until their registration was reinstated; 
APA: 60 members responded to a survey by the APA, of which
30 per cent stated that they did not get a renewal notice, 60 per
cent said that they had paid renewal fees but which were not processed by
AHPRA, and a quarter said that they had made an online query but got no reply
Australian Private Midwives Association: an estimated 50 members
in Queensland were not notified or were given incorrect paperwork, and approximately
another 30 or 50 in Victoria were not notified;
Australian Psychological Society (APS): an estimated 500
members in Victoria alone failed to renew their registration, with between 50
to 100 members from Victoria contacting the APA with their concerns about the
registration process, and, in addition, a further 30 members from Queensland
had not registered and had not received any communication from AHPRA;
Australian Association of Psychologists (AAP): 570 psychologists
were deregistered in Victoria and 130 were deregistered in Queensland.
However, witnesses explained that the figures provided were only
indicative, as concerns regarding registration may have been voiced with other
membership organisations, or with state branches as opposed to national offices.
Further, the volume of those affected varied based on the state based
composition of their membership, with some states being more heavily affected
Associate Professor Rait commented that:
...out of the other organisations we have a disproportionate
number of West Australians. As a result of that, I believe we have had fewer
problems, because as we have heard the system as it was introduced was delayed
because the government of West Australia wished to further modify the
legislation. As a result, some of the issues were improving in Western
Australia and the registration problems were not as paramount or as
AHPRA also provided the committee with the number of registration
renewals across all professions under the NRAS, noting that 7.2 per cent of
registrations which were due to be renewed, lapsed:
Since 1 July 2010, AHPRA has finalised approximately 370,000
renewal applications, with 345,000 renewals due by 31 March 2011. In the period
between the start of the National Scheme and 31 March 2011, the registration of
approximately 24,894 practitioners lapsed. This represents 7.2% of all
practitioners who were due to renew their registration in that period. While
comparative performance information is patchy, AHPRA has found no evidence that
there are more practitioners not renewing their registration than was the case
in the past.
While the APS noted that according to the Psychology Board of Australia,
the number of practitioners affected by registration issues under AHPRA are
similar to the number of those affected in the past, the majority of witnesses across
a number of professions explained to the committee that in the past it was
unusual for practitioners to have issues with registration. It was argued that the
volume of difficulties experienced with the registration under the new system
Professor Claire Jackson, RACGP, stated:
The amount of time and the degree of angst that this
registration this year has caused our members and the number of phone calls and
requests for us to intervene that have come through from our members are of
This was supported by Avant Mutual Group Limited, who submitted:
Whilst the majority of doctors seek assistance in relation to
complaints and the investigation process relating to complaints, since 1 July
2010 there has been a substantial increase in the number of doctors who have
sought assistance in relation to registration issues.
As further evidence of the number of health practitioners affected by
the implementation problems, representative organisations provided evidence of
the considerable increases in their workload, particularly in negotiating and
liaising with AHPRA on behalf of their members. As a result, practitioners,
service providers and representative bodies have had to divert a significant
amount of time and resources to deal with arising difficulties.
Professor Littlefield told the committee that the APS had to employ extra staff
to handle all of the extra enquiries and concerns generated in response to the
difficulties experienced with the registration system:
...AHPRA were referring them all to us. So they did refer
these inquiries to us and the impact of that was enormous. We had to put on 13
staff for six months to handle the inquiries...
While the Australian Osteopathic Association noted that their members
have been affected by organisational and administrative problems since the
implementation of the NRAS, they submitted that most of their members had not
experienced delays or errors with their registration under the new system.
However, AHPRA informed the committee that it is not possible to
directly compare the extent of problems arising out of the NRAS registration
process with the state and territory based schemes in place before
1 July 2010, as 'key features are different'.
Mr David Stokes of the APS noted that that there were certainly
differences between the previous systems and current registration processes,
which may have affected the number of practitioners who did not re-register,
stating 'in previous stages there was a three-month period of grace, if we can
use that term, while the matter could be sorted out. This was a one-month
Professor Littlefield further qualified that:
I think it is not to do with number, it is due to the impact
of what has happened. It is these people who were totally unaware that they
were unregistered and the huge impact of that. So impact is enormously
different to previous years even if numbers are not so different.
The number of registrants adversely affected by problems in the
registration process undertaken to date by AHPRA is significant and far
exceeded anything experienced under the old registration system. The committee
considers that the number of health practitioners facing problems with the
registration process had the potential to severely compromise the delivery of
health services across Australia.
The effect of poor administration on individual practitioners
Mr Robert Boyd-Boland, ADA, summed up the impact on practitioners:
We have all been affected. We have all been required to
undertake the registration process. It was a new process. It was a process that
they were not familiar with. It was a process that a reasonable percentage of
them struggled with. They were all affected.
The committee received evidence that as a result of the poor processes
under the NRAS, many practitioners experienced loss of income, damage to
reputation, inconvenience and stress.
Ms Liesel Wett, Pharmaceutical Society of Australia, explained that the
registration of health practitioners affects both the livelihood of
practitioners and service delivery to patients, and therefore it is imperative
that the current issues be addressed.
In many cases practitioners were not informed of their registration
renewals, received misinformation about their registration even when paperwork
had been completed and fees had been paid, and also had difficulty contacting
AHPRA to renew or check the status of their registration.
The Australian College of Rural and Remote Medicine submitted that delays in
medical registration renewals under AHPRA:
...created a high level of anxiety and stress for the doctors
generally as well as adversely affecting their ability to see patients and
generate income during the relevant period. Employers of those doctors who had
experienced delays in registration renewals were also impacted adversely.
The AMA submitted that in their view, it is unacceptable the AHPRA's
poor administration and processes have had such devastating impacts on
The impact of non-registration as a result of poor
administration, or administrative failure by AHPRA is very significant. Once a
medical practitioner learns they are not registered they cannot practice
medicine. If a change in registration category was delayed i.e. provisional
registration to general or specialist registration, the medical practitioner
could not commence in their new position. In both cases the doctor cannot earn
an income, and there are fewer medical practitioners available to provide
medical care to patients...it is unacceptable that even one practitioner who
met all of the registration requirements and application deadlines was unable
to work as a result of administrative delays or failures.
A number of witnesses told the committee that a significant issue has
been the deregistration of practitioners without notification.
The committee was informed that in the case of optometrists, registration
difficulties resulted in the registration of a number of optometrists lapsing,
which prevented them from practicing and impacted on patient care, the
optometrists themselves and of course their practices.
The Optometrists Association of Australia explained that where possible,
optometrists tried to ameliorate the effects of this on their patients,
however, the only way to address the problems faced by the practitioners was to
try to re-register:
...optometrists affected sought to minimise the impact on
patients by rescheduling appointments with other optometrists in their practices
or even by sending them to competitors. While they could assist patients where
possible, the only remedy for the optometrists themselves was to get back on
the register as fast as possible.
The committee also heard that the delay in processing applications has
had a very real impact on practitioners. Before the introduction of the NRAS,
the assessment of applications by nurse practitioners was assessed by state and
territory nursing boards. The Australian College of Nurse Practitioners (ACNP)
submitted that when the NRAS commenced on 1 July 2010, no guidelines had been
made available to the AHPRA branches detailing how to process the applications
for nurse practitioners (NP). As a consequence, some applications have sat for
over eight months with no assessments occurring. The effect on nurses waiting
for their applications to be processed so that they could gain endorsement and
commence work as a nurse practitioner has been significant both financially and
professionally. The ACNP stated:
The lengthy delay has taken a heavy professional and personal
toll on the NPs who have had to wait extended periods for the applications to
be processed as they were unable to practice and function at the level they
were qualified and experienced to perform.
Case study 4.1
am a trauma specialist. I was for 21 years registered as a psychologist and I
was on-site at the Bali bombings and the Port Arthur shootings. I was a prime
ministerial adviser to John Howard during the Indian Ocean tsunami and many
other major international disasters around the world. You mentioned the floods
in Brisbane. I turned up at the royal national association evacuation centre
during the floods to see the 1,300 or so evacuees who were staying there. I
came in as a volunteer to assist as a trauma expert and was welcomed by people
who knew me and knew of me. Within an hour of my volunteering to assist, I was
asked to leave the premises because a screening was done and I was found to be
deregistered. I had no knowledge of that at all. So this very humiliating
situation impacted on me professionally and also upon thousands of people who
were in the evacuation centre because I had to leave the premises and was not
able to offer any services at all.
I spent the rest of that day on the phone to AHPRA and
the PBA to try and work out why I was not on the register. I had looked at the
register, I saw that I was not there but I had heard nothing from them. I knew
that the renewal date had passed because in fact I wrote to AHPRA two weeks
before the renewal date to tell them that I had not received a renewal notice
and to ask if they could please send it in a timely manner. I heard nothing
from them. Then we got involved in the floods and I did not follow it up, only
to find that I was deregistered. I got a letter that was dated some eight days
earlier, which may have been held up in the floods, and so I had been working
for eight days unregistered without knowing about it. Of course, I would have
had legal liability because my professional indemnity insurance would have been
null and void.
Because I do not do a lot of work for Medicare, I did
not have a Medicare problem at that time, but I do do some work for Medicare.
So what I had to do was cease work immediately because I was threatened with a $30,000
fine if I worked. Then I found out that my Medicare provider numbers had been
cancelled. I asked AHPRA if they would please take responsibility to reinstate
that. They refused outright and said it would be my responsibility to do so. I
was able to get back on the PBA register by sending an article to the
Courier-Mail and explaining my plight in relation to the people at the
evacuation centre. Within half an hour of the Queensland psychologists board being
interviewed by the Courier Mail journalist, the Queensland psychologists board
rang me and said they would fax out a fast-track renewal. I cleaned that up
pretty quickly. I got that back to them and I got back on the
register...Anyway, I was back on the register but I still could not do any
Medicare work because it took a month to be reinstated back into Medicare...the
effect on people's livelihoods and their reputations is unquantifiable in lots
of respects. You do not just lose the money for that period of time; you lose
the next six to 10 or further sessions that you might have with a patient. You
lose up to 18 Medicare sessions for the next year for every Medicare client
that you lose under those circumstances. AHPRA has not reinstated me as a
registrant from 1991. My date of first registration now reads 27 January 2011,
and that is not satisfactory either. But I do not know how much this is going
to come to in terms of cost. I am yet to talk to my lawyer bout how to quantify
that kind of cost.
Source: Mr Paul Stevenson,
President, Australian Association of Psychologists, Committee Hansard,
4 May 2011, pp 66‑67.
MDA National Insurance explained to the committee that some of the new
requirements of the registration system have resulted in significant delays in
the processing of registration applications, to the detriment of the medical
practitioners involved who are unable to work until their registration is
...members attempted to register on time, but their
applications were delayed impeding investigation following self-disclosure of
past health issues. Investigations did not commence until after the members
were due to commence their employment, leaving them unable to work. This was
obviously an unexpected and unfortunate outcome for those practitioners
The committee also heard that AHPRA's poor administration and
communication has caused significant frustration and distress for a number of
practitioners. The Australian Nursing Federation(ANF) explained:
Letters were sent to nurses and midwives informing them that
they would be deregistered as they were not renewed, when in fact they had
renewed their registration but AHPRA had not updated the register. This caused
distress to members as nurses and midwives take their right to hold
registration seriously and will not work without registration.
These issues were reflected across a series of professions, and the
committee heard a number of examples similar to that provided by the Pharmaceutical
Society of Australia (PSA) in relation to the experience of pharmacists who
were trying to have their queries and concerns addressed by AHPRA:
They could not get through on the 1300 number. There was no
answer. Their emails remained unanswered...Even when they did finally manage to
get through on the numbers, because the operators were unable to assist them
they were then asked to lodge email queries instead, which then went
The committee heard that even representative bodies and healthcare
service providers had significant difficulty contacting AHPRA, indicating a 'systemic
lack of communication not only with those registrants but also with their
Witnesses explained that there was only one contact point, 'an e-mail or a 1300
number', regardless of the seniority of the person contacting, or whether they
were an individual or organisation. Ramsay Health Care Australia elucidated:
We feel that we did not as an organisation have an 'in' to
somehow get into those more senior levels when we are looking at quite
significant impact across healthcare service provision.
Ms Spaull informed the committee that Ramsay Health Care Australia has
had to institute its own mechanisms for ensuring it has correct and up-to-date
information regarding the registration of their employees, as it is not readily
or reliably provided by AHPRA:
Also, just to further your understanding when we talk about
lost shifts and lost hours, whenever we had someone who was struck off the
register—in, I would have to say, nearly 100 per cent of the cases—this became
known to us through our multiple registration track. Through our internal
mechanisms of communication, we actually encouraged every nurse and every
allied health professional to log on for themselves and see where they were at,
and often that would reveal problems: 'Oh my gosh! I've paid but I'm not
registered.' So it would come about almost by accident that we would find out.
They did not receive letters willingly from AHPRA. You will see in our folder
that we actually had to draft letters with legal to create a sense of communication
and documentation around these serious incidents where people had been
practising and were not aware that they were not registered. We pulled them off
the ward immediately.
The committee received evidence that the communication and accessibility
issues that many organisations and individuals experienced with AHPRA have not
been addressed. Mr Gavin O'Meara explained, 'It is still difficult to get in
contact with key people, and it is difficult to get in contact with people who
have the knowledge to solve the problems'.
In a similar vein Ms Liz Wilkes, Australian Private Midwives
Association, explained to the committee that the difficulties experienced with
the registration process have been significant, and the issues that most of the
Association's members are having with AHPRA remain outstanding:
Only 30 people have actually managed to get through the
process. There would be at least another 70 or so seeking eligibility who are
in some part of the process. There are another 38 in Queensland that are in
some way along the track of the process. We find that they submit their
application and they are then required to submit more information. We have got
a huge email trail around what is being required in addition to what they have
already submitted...there does not seem to be any single point of
accountability, or it is very difficult to find a single point of
accountability around eligibility notation.
Dr Hambleton noted that the AMA's members now have little confidence in
the registration system:
I can tell you that the confidence of the members from
Queensland is very low that, when they put their forms or dollars in, they will
actually get actioned in an appropriately reasonable time frame.
Impact on practitioners' reputation
The committee heard that one of the most concerning effects of the
problems with the registration system is the deregistration of practitioners
and the impact this has on the practitioner's reputation, which can be very
distressing for those affected. This was evidenced by the ADA's submission:
In some instances, some practitioners, thinking that they had
correctly followed the registration process, found that through delays
occasioned at AHPRA with their registration process, they were in fact not
registered and thus had claims made on Private Health Insurers and Medicare
refused. Whilst AHPRA has since attempted to deal with this issue, severe
reputational damage has been suffered by the dental practitioner.
MDA National Insurance informed the committee that five of their members
had been deregistered, and all but one have now been successfully
Dr Hambleton described the impact that deregistration can have on a
As a medical practitioner, I cannot overstate how devastating
it can be when you find yourself not registered and not being able to practise
medicine and earn a living. There is devastation for the doctor's family...The
fact that many doctors found themselves in this very situation is appalling.
The committee received evidence that physiotherapists also had concerns
about how their deregistration by AHPRA had affected their reputation as
Other physios have been concerned that there was a perceived
loss of reputation, that new patients were cancelled and went elsewhere and
wondered why this person was not registered.
The committee was further informed that the deregistration of
practitioners also affects the patients, in particular, it can have a
deleterious impact on a patient's confidence in their practitioner:
One impact is not being able to see a particular doctor or
the waiting times increasing substantially. The second impact is the decrease
in confidence in the practitioner that they are seeing. A lot of the time we
have international medical graduates. We need to maintain confidence in our
colleagues from overseas to make sure that they can do the job that they are
brought here to do. If an international graduate is deregistered and the
patients find out, they come back and say, 'How come he was not registered last
week, he is registered this week and he was the week before?' So the confidence
in the practitioner is almost as disturbing as the fact that they could not see
The APS explained to the committee that practitioners had to explain
their deregistration to clients:
Being characterised as 'unregistered' is damaging to a
practitioner’s reputation and not meaningfully understood by clients. It was
necessary for the full explanation to be given to all clients to explain the
cancellation of services. No offer to remedy this slur on the reputation of the
psychologists was ever made by AHPRA.
The committee acknowledges the devastating impact of AHPRA's administration
of health practitioner registration on the livelihoods of health practitioners,
on the operation of practices and health service providers, and also on patients.
Further, the committee notes the detrimental impact to the reputation of
practitioners and patient confidence in practitioners due to AHPRA's
substandard management of the registration process. The committee is concerned
that AHPRA's poor administration has led to delays in the processing of
registrations, the deregistration of practitioners, the provision of incorrect
information, and the provision of insufficient support for practitioners, which
have had a very real impact on the lives of practitioners and their patients.
Financial and economic loss
Once of the more serious issues arising out of the difficulties with the
registration process was that due to delays in the processing of registration,
the deregistration of practitioners or the amount of time taken to follow up
registration issues with AHPRA, a number of practitioners across all professions
found themselves unable to work and earn an income.
Dr Hambleton explained to the committee that the financial implications
of a practitioner not being able to work for a period of time can be
'devastating', as often, general practices 'run very close to the financial
line', so even having one practitioner who is unable to work for several weeks
can have serious financial consequences.
The evidence provided by MDA National Insurance supported these comments, and
While we were not able to quantify the potential actual
economic loss that practitioners suffered, we were aware that some
practitioners have ceased practising until such time as their insurance and
registration requirements were finalised.
The committee received evidence that due to the delays in registration
processes, some nurses and midwives were unable to work and therefore unable to
receive a wage:
Some nurses and midwives subsequently had to forgo shifts as
they could not provide evidence of registration to their employer and therefore
were financially compromised. 
For the committee's information, the APA provided an example of how the
registration issues have impacted practitioners in a financial sense:
One private practitioner in Queensland was removed from the register.
She received no correspondence from AHPRA. She checked the online register when
the APA notified our members that there were problems. She is a small business
owner with 20 or so clients per day. She was forced to cancel three days worth
of clients because of the issue. She had been indirectly affected by the
Queensland floods and she had already lost thousands due to closure and power
failure. She was worried that if this were not rectified her business would not
survive the loss of thousands of dollars more from cancellation of clients.
The committee was told that as a result of the registration issues
experienced, some psychologists were unable to work and some even lost
patients, to their financial detriment:
So those people could not see any patients for quite some
time, until they got back on the register. A lot of them lost income and lost
their patients, although a number of them continued to just work—or not work,
because they were not registered, but support somehow their patients by trying
to get them somewhere else.
Case study 4.2
Avant assisted a doctor, whose registration
incorrectly contained an entry indicating that he was subject to conditions on
his registration. This was pointed out to AHPRA and was eventually corrected,
but this took a number of days. This had a particularly significant impact upon
the doctor concerned who had developed a locum business. With remote locum
positions the communities require doctors to be available at the earliest
possible time and the doctor loses substantial amounts of income for each day
he/she is unable to work. The doctor concerned was unable to apply for locum
positions whilst there was a suggestion that his registration was subject to
It was therefore harmful not only to the doctor, but
also likely caused inconvenience to patients in the areas where he could have
worked but for the conditions. In another case, it took several weeks to
correct the register of details for a locum physician.
Mutual Group, Submission 12, pp 5–6.
The Optometrists Association of Australia submitted that practitioners
whose registration had lapsed suffered significant loss of income, with over
100 optometrists remaining unemployed until they were re-registered. The
Optometrists Association of Australia acknowledged that the fast track
re-registration system had the potential to mitigate loss of income, however,
stated that it is unclear to what degree this was taken up, or how effective it
was in practice:
Where a lapsed registrant applied immediately for Fast Track
re-registration and was restored to the register within 48 hours, the loss of
income was limited to just a few days. However, we do not have statistics about
how long re-registrations actually took and of how many lapsed registrants did
not seek Fast Track re-registration because they did not realise it was an
option available to them.
Mr Boyd-Boland also explained to the committee that the financial impact
of the registration issues is not quantifiable, as it has been absorbed by individual
practices. However, he provided the committee with a description of the
practical implications of the registration difficulties experienced by dental
practitioners, who practice in:
Largely office based practice, single or two-person practices
so, when problems arose and there needed to be clarification through AHPRA, it
took the dentist out of circulation insofar as provision of treatment was
concerned for the duration of the inquiry that was made to AHPRA. From the
accounts that I have received the length of time that it took to obtain
clarification varied from hours to never...I am sure when the problem
crystallised they were able to deal with a lot of it perhaps out of hours but
the office hours of AHPRA coincided with surgery hours, so when there was
direct communication with AHPRA the dentist was out of circulation.
The delays in the processing of registration applications also affected
the wage which those practitioners completing their intern year, were able to
be paid. Some provisional registrants were unable to obtain full registration
because they were told to fill out the incorrect form and consequently 'they
were employed as interns on intern pay not on PGY2 pay'.
Ms Wett, PSA, explained that the delays in processing registration
applications and renewals has had considerable impact on both pharmacists and
Many interns who were eligible to commence employment and
therefore earn a living as a pharmacist were unable to do so as they
experienced significant delays in their registration and their papers being
processed and were left in the dark while waiting, as information from AHPRA
was inaccurate, conflicting or not available. This also had a flow-on effect to
other pharmacists who were unable to take leave as planned, on staff rosters et
cetera. People had to reschedule their holiday leave, bring in locums and pay
high fees to locum agencies to source them on short notice.
The committee further heard that currently there do not seem to be any
suggestions on how to address this loss of income for practitioners who were
unable to practice due to AHPRA's administrative failures:
...individuals rely on their ability to generate an income.
There was a gap for a lot of individuals where they were not generating income.
We certainly know about doctors who are misclassified in the public sector
whose income is down. I do not think there is any remedy at this stage for any
The AMA suggested that a compensation scheme for any future events
should be considered:
While it would be difficult to set up a scheme to
retrospectively provide compensation for financial loss as a result of
non-registration because of the transition to the national scheme,
consideration should be given to establishing a scheme for future events.
The committee was told that Ramsay Health Care have extrapolated the
costs of the registration issues to the health industry between 1 July 2010 and
1 January 2011 to amount to 'in
excess of half a million of dollars of labour'. However, Ms Spaull noted that
this figure is not inclusive of all of the impacts, 'I do not think we can
measure the toll on committed healthcare professionals supporting their
colleagues and the organisation in the interests of patient safety, but
nevertheless it is ever present'.
Cost of registration
Witnesses also told the committee that a further financial implication
for practitioners under the new registration system is the increase in the cost
of registration, which could also affect patients. The RACGP noted concerns
regarding increased registration costs, with doctors now paying 20 to 60 per
cent more for registration. Professor Jackson explained:
It has become a far more expensive system and, as I said, we
are worried that we are going to have to pass those costs on to our patients.
There are no part-time opportunities to reduce costs. Most organisations charge
far less for doctors with family responsibilities who are doing two or three
sessions a week than they do for full timers, but medical registration is not
Mr Boyd-Boland informed the committee that dental practitioners have also
been impacted financially by the substantial increase in registration fees:
They have all been affected, quite simply, in a financial
sense in that the registration fees have significantly increased. In our
submission we quoted that it was $250 for registration in Western Australia and
it has increased to $545.
The committee heard that this financial impact will have significant
implications for academics in the field of dentistry:
There is a significant shortage of academic staff in
universities training dentists. I have an instance of one member who sought to
register. He lectures two days a week and, for first-year students in a
pre-clinical area, there is not a patient to be seen. He is required to
register. His existing registration fee is $101. He had to reapply, so that is
$275, and then apply for registration, $545. In an environment in which we are
struggling to get academics into the universities that is a big negative for
that person. I am sure there are other academics in a similar situation.
The AMA further pointed out:
...I would stress the point that we were given every
indication there would not be an increase in personal fees. So if the budget of
$20 million was inadequate then I hope we are not working on an assumption that
there will be a continued cost shift to the professionals in order to crank
that budget up.
The committee is of the view that the exposure of practitioners to loss
of income and financial risk due the inability of the national health
practitioner registration authority, AHPRA, to adequately perform its
functions, is deplorable.
The committee notes the estimated financial impact for six months of
this debacle exceeds $0.5 million in labour, and is concerned that there do not
appear to have been any support systems put in place for those practitioners
and service providers who suffered loss of income.
The committee is very concerned that on top of the financial risk
already faced by many practitioners, practitioners are also facing
substantially increased registration fees. The committee notes the impact that
this may have on academic staff and the consequent possible implications for
the training of practitioners.
The committee particularly notes comments by the AMA and agrees that any
shortcomings in the projected budget for the NRAS should not be recovered
through increases in registration fees.
Implications for Medicare benefits and private health insurance claims
The committee received evidence that the deregistration of practitioners
also affects the ability of patients to claim Medicare benefits.
MDA National Insurance explained to the committee those practitioners who are
not registered will have their Medicare provider number cancelled:
We were also given to understand that AHPRA has advised
Medicare of those practitioners who had not reregistered and Medicare has
cancelled their provider number, which removes the entitlement to remuneration.
It is not clear at this stage to us if Medicare will seek reimbursement of
these billings. In respect of dentists it is unclear to us whether health funds
will similarly demand reimbursement for payment made while a practitioner was
The Australian Private Midwives Association further noted that the
delays in processing registrations have left midwives without Medicare provider
numbers, and consequently their clients have been unable to claim Medicare
Around the eligibility component there are at least 20 to 30
practices that have been significantly impacted by delays. These have been when
midwives have expected to have eligibility so that they could get their
provider numbers and they have met all the criteria but were not processed. So
the women who were seeking care were expecting a Medicare rebate and were
unable to get it for their care. It would be $700 to $1,000 per birth package.
If you had 30 midwives that had delays and they are all taking 40 women a year,
you do the maths. It is fairly significant.
The committee received evidence stating that as some practitioners were
deregistered without notification, and therefore continued to practice without
registration, their patients were not able to claim Medicare benefits. Professor
Littlefield explained to the committee that many psychologists and their
patients were exposed in this manner:
There has been a shocking impact because many of those
psychologists did not know they were not registered, so they continued to see
their patients and then when the patients went to Medicare to claim the rebate
they discovered that the psychologist they were seeing was not any longer
registered. So the patient was impacted on by not being able to get the rebate.
There was an enormous impact on the patient in how they viewed the psychologist
and then they had to tell the psychologist that they were not registered.
This situation was also detrimental to the treatment of patients. For
example, the APS stated:
Clients with serious mental or physical health issues without
warning were no longer eligible for Medicare rebates and in most cases their
treatment was disrupted. In Queensland this error occurred in the midst of the devastating
January floods, which meant traumatised clients could not access treatment from
psychologists affected by the registration renewal debacle.
Further, the committee heard that there is 'potential for other claims
for payment being affected, such as WorkCover or motor accident insurance
rebates, and definitely health fund rebates'.
In particular the committee was told that physiotherapists were concerned that
private health funds and other payment claims would be affected:
There have been concerns about the fact that private health
funds would not rebate once they found out that the treating therapists were
not registered in that time, and who would repay what had already occurred with
our HICAP system where it automatically goes into the practitioner’s bank
account when the patient is refunded at the point of service.
There are issues around workers comp, Department of Veterans'
Affairs, and other mechanisms where there are third-party payers. For example,
if I treat children, trust funds might pay the amount but will request refunds
if they find that you are deregistered.
This was validated by AHWMC who submitted that:
Because claims for benefits through the Department of
Veterans Affairs (DVA) and private health insurers rely on data from Medicare
Australia, there was potential for DVA and private health insurance (PHI)
claims to also be affected.
Mr Stokes elaborated that even under the fast track renewal process, it
took a number of weeks to be able to re-register and then reactivate a Medicare
We had people who even with a fast-track renewal, as was
mentioned, took three weeks, and all that time they are unable to practise,
essentially, and they are certainly unregistrable with Medicare. Not until you
are fully reregistered can you go back to Medicare and say, 'May I have my
provider number reactivated?' That was reasonably efficient once you got AHPRA
to do its work. So it was a pretty critical situation.
The APA explained that they had:
...been assured or given some undertaking that there will be
a period of grace or if it is seen that it was definitely not the registrant’s
fault that rebates through Medicare would be reintroduced, et cetera.
While Dr Hambleton noted that the minister had 'thankfully indicated
that she would support act of grace payments for patients', Ms Kerry Flanagan,
Department of Health and Aging, noted that there are some Constitutional
considerations around the Commonwealth's ability to make ex gratia or act of grace
As I understand it, this is a Constitutional issue in that
the power to regulate health professions actually resides with the states and
territories and not the Commonwealth. The legislation to set up this national
scheme was passed in each parliament across the nation. There have been
discussions, and again I can provide more detail on notice in terms of what the
issues are around ex gratia and act-of-grace payments and whether there is
redress at the Commonwealth level considering the makeup and the legislation
which governs this particular scheme.
However, Ms Flanagan explained to the committee that the Commonwealth
has identified a different approach to ensuring that Medicare claims can be
reimbursed, which does not involve ex gratia or act of grace payments.
AHPRA submitted that, where a practitioner has experienced administrative
difficulties in renewing their registration which has resulted in their
registration lapsing, and continuity of registration status can be established,
AHPRA will 'adjust the date of the practitioner's new registration so that it
begins immediately after his or her previous registration lapsed'.
Ms Flanagan informed the committee that 'in effect the consequence of it is
that there is no lapse in registration, which means that Medicare can then pay
The AHWMC further elaborated on how the problems regarding Medicare
benefits were being addressed:
AHPRA established a fast-track process to assist
practitioners to return to the register as quickly as possible. In addition, a
procedure was established to address registration issues for practitioners whose
registration was affected by transitional issues (such as incorrect address
details held on the AHPRA database). AHPRA has written to practitioners who
fast tracked their registration because they had missed their renewal deadline
in November and December 2010 due to the new arrangements. These practitioners are
now able to complete a statutory declaration up until Monday 2 May 2011, if
they believe that their registration has been incorrectly dealt with.
AHPRA will advise Medicare Australia directly that the
provider is registered and Medicare Australia will then seek to process the
practitioner's record within two days of receipt of this updated information,
allowing patients to resubmit outstanding or rejected bulk bill claims. This
procedure has ensured continuous registration and the payment of Medicare and DVA
benefits to affected practitioners and their patients.
...Where the AHPRA procedure addresses registration issues
for a practitioner for the purposes of Medicare, it also addresses registration
issues for associated PHI claims.
Associate Professor Rait noted that only a few practitioners may have
claimed Medicare benefits for the period that they were no longer registered.
Of the cases that he was aware of, Associate Professor Rait noted that Medicare
had honoured the payments and backdated the registration of all cases but one.
He further stated:
As far as I am aware, only one person potentially could be
asked by Medicare to repay those payments...As far as we see, it has only
affected one member potentially. Obviously we would be anxious that they were
not subject to any sanctions, particularly repayment of benefits, and the
inconvenience to patients that that would cause. If the Commonwealth could be
flexible that would be appreciated.
Case study 4.3
The following account was provided by a medical
practitioner who had been deregistered without her knowledge, due to AHPRA's
failure to process her application in a timely manner:
On 1/3/2011, staff at the medical practice at which I
work received a phone-call from a clerk at the local Medicare office to notify
us that a Medicare claim for one of my patients, whom I had seen in late
February, could not be processed because I had been deregistered. The staff member
contacted me, but as I was out of the office doing home and hostel visits that
afternoon, I did not follow it up till the next morning when our senior office
staff member contacted AHPRA and confirmed that I was indeed deregistered.
Patients with appointments for that week were contacted to make other
arrangements. Some patients were able to see other doctors in our practice and
others were able to take appointments at a later date. There were some patients
who had complex and urgent needs that I wished to follow up. I also am
responsible for the care of nearly 60 residents of aged care facilities...Normally,
if the nursing home or hostel staff have any concerns with these residents,
they contact me directly, day or night, seven days a week. Being unregistered I
was unable to give any direction on the care of these patients.
I did not have any difficulty contacting AHPRA staff
by telephone...They also advised me that I should write on the fax cover note a
request for backdating of my registration to cover the period of my
deregistration. Backdating of registration is not automatic in the situation of
deregistration and would only be considered on receipt of a request in writing
and under certain circumstances like my own and would take longer than 48 hours
to process. On 2/3/2011 with the cover note as advised, I faxed the fast track
renewal application to AHPRA...
After raising her concerns with AHPRA, the doctor
received the following correspondence from AHPRA:
Thank you for your time on the telephone this morning.
I appreciate you confirming for me the issues in your contact with AHPRA. I
confirm my apology for the human error within our office which led to your
registration lapsing and for the very significant consequences of that error
for you, your practice and your patients.
I also confirm that advice was provided to Medicare
Australia on 9 March 2011 that your registration had been lapsed in error and
had been reinstated without any gap in registration dates. I trust this will
enable you and your patients to follow up any outstanding matters with
Whilst I sincerely hope your future contacts with
AHPRA enable seamless continuation of your registration, you should not
hesitate to contact me if you wish to discuss this or any other matter.
Sandra Gaffney, Submission 210, pp 3–5.
The AMA noted the measures instituted to address the issue of
reimbursing Medicare claims, however, remained concerned that 'there is no
guarantee that all patients who should have received their benefits will in
fact receive them.' Further, the AMA emphasised the fact that the problems with
Medicare claims, and the subsequent mechanism to address the problems, have
culminated in a significant burden for practitioners:
The mechanism requires the medical practices to resubmit
rejected claims. Practices will also have to tell their patients that they can
resubmit their claims for benefits. We are concerned about the additional costs
imposed on medical practices for having to rectify this problem on behalf of their
patients, and had hoped for a more automatic solution for these practices.
As a result, the AMA suggested that it is essential that communication
between Medicare and AHPRA improves:
Firstly, there must be a mechanism to ensure that medical practitioners
are advised by AHPRA that they are no longer registered, and not by Medicare
Australia. Secondly, there must be a sufficient period of notification before
the registration is cancelled so that medical practitioners can put in place
appropriate arrangements for patient care. Finally, as a stopgap measure,
before cancelling access to Medicare benefits Medicare Australia should first
check whether a practitioner is billing Medicare items and if so double check
the registration status with AHPRA.
The committee is dismayed that the failure of AHPRA to undertake its
principal function in an efficient manner has resulted in deregistration of
health practitioners and thus precluded patients being able to claim Medicare
rebates. AHPRA's failure to notify practitioners that their registration had
lapsed, prevented practitioners from being able to practice thereby exposing
them to potential loss of patient confidence, exposing patients to an
unnecessary financial impost, and in some cases, interrupted treatment.
Further the committee remains concerned that despite the mechanisms
agreed to by AHPRA and Medicare Australia to reimburse Medicare claims, not all
patients are guaranteed to receive these reimbursements.
Legal liability - professional indemnity insurance
The committee received evidence stating that in some instances, practitioners
across all professions had continued to practice, in the belief that they were
registered, when in fact, they were no longer registered by AHPRA.
It was noted that this could have consequences for the legal liability of the
practitioners, and also impact on patients:
Clearly the implications of not being registered could have
had a direct bearing on practitioners’ indemnity, which of course is a concern
to us. The respective professional indemnity insurance policies obviously cover
medical and dental practitioners in our case, and each define the practitioner
as being one who is registered to practise their profession. In addition, the
policy excludes claims to the extent the claim arises when the insured was not
registered or was prohibited from practising.
In their submission to the committee AHPRA also acknowledged the
potential consequences for practitioners who practice without being registered:
Professional indemnity insurance policies held by some
practitioners may limit the liability of the insurer, or exclude coverage
entirely, in circumstances when the practitioner has engaged in unregistered
Similar concerns were expressed about the consequences of optometrists
continuing to practice without being aware that their registration had lapsed,
particularly how this might affect their professional indemnity insurance.
Specsavers submitted that as a result, lapsed registration:
...could lead to professional association disciplinary
actions and a lapse of professional indemnity insurance which has obvious legal
liability consequences for the optometrist, their patient and their employer.
The committee heard that due to concern about the possible legal
implications of staff who were unaware that they had been deregistered, and
therefore had continued working, Ramsay Health Care Australia have analysed and
documented any possibly adverse situations on their own initiative:
One of the reasons we captured this data—it is actually
almost ironic in that we did not intuit a public hearing—is, if you like, as
protection in the future should something come up. We wanted to have evidence
of email trails. So it was actually done, if you like, to document evidence
that we had done everything we could to be lawful in a system that was very
turbulent and challenging.
When one of these situations would happen, we would have a
teleconference between the staff member involved, me and the CEO of the hospital;
we would draft a letter and have them sign a stat dec stating that they
actually got legal advice. So it was very procedural in managing this. We did
not have a lot of advice from AHPRA on what to do, so we relied on our own
In light of this work, Mr O'Meara informed the committee that Ramsay
Health Care Australia have not identified any significant outstanding issues:
We have a fairly good idea, because I can assure you we have
gone back and looked at the activity or any adverse event that might have
resulted from a person working during a period of time when they were
potentially not registered. So we have had a look at that. We are able to
identify that at this stage, and from what we can see there are no significant
outstanding issues there.
The Optometrists Association of Australia noted that AHPRA has indicated
their willingness to backdate registrations to the date of the lapse in
circumstances in which 'AHPRA error contributed to the lapse'. While this
should mitigate the insurance risks for patients and optometrists, it was noted
that currently, it is unknown how many of the lapsed registrations will be able
to be backdated in this manner.
In addition, as a result of the current situation arising from the
registration issues experienced, professional indemnity insurers have indicated
that they will 'be extending indemnity to those practitioners that perform
services innocently or unknowingly whilst not registered'.
MDA National Insurance submitted:
In response to these unique circumstances, MDA National
Insurance will hold as indemnified practitioners who have a gap in their
registration due to the delays, provided registration is eventually granted.
However, we will only apply this concession in this transitionary year 2010/11.
This has required negotiation with our international reinsurance partners.
Associate Professor Rait continued:
Clearly if registration has lapsed through no fault of the
practitioner and an incident arises, we would otherwise have been liable anyway
and our reinsurers agree that that lapse is not due to any fault of the
practitioner, nor should they be held accountable for that. As a result, we are
quite happy that through our negotiations with our reinsurers we can indemnify
all members who have so been exposed.
Further, AHPRA added that it is unlikely that practitioners would be
successfully prosecuted for unintentionally practicising while unregistered:
The National Law creates an offence for a person who
knowingly or recklessly holds themselves out as a registered health
practitioner. Therefore, a practitioner who inadvertently fails to renew
registration and continues to practise his or her profession is highly unlikely
to be found by a court to be in contravention of the National Law.
Witnesses noted the undertaking by professional indemnity insurers, but
pointed out to the committee that it is uncertain how any such cases may be
received in the court:
We understand that the indemnity insurers have offered to
support the practitioner's periods when they have been deregistered through no
fault of their own; however, that has never been tested. So, if there are
issues and cases that come up in the period when they were technically
unregistered, we have no idea what the court's view on that will be, particularly
for practitioners who continued to see patients in the belief that they had
looked after all the details and subsequently found out that they had not.
In addition, the AMA submitted that the legal implications of AHPRA's
imprecise administration are ambiguous:
Further, we are unclear about the legal implications for
medical practitioners remaining on the public register with an expiry date on
the register, even though AHPRA advice is that if a medical practitioner
appears on the register, they are deemed to be registered regardless of the
The committee also heard that the professional indemnity requirements
under the new system are of particular concern to self-employed midwives. Ms
Wilkes of the Australian Private Midwives Association noted that under the new
system AHPRA requires all health practitioners to have professional indemnity
insurance – while the Association welcomes this, Ms Wilkes explained to the
committee that this has created difficulties for self-employed midwives:
...a significant number of our members are impacted by this
change and are unable to meet the requirement. There is no satisfactory
insurance product available to cover all elements of a self-employed midwife's
practice. We believe that we are significantly disadvantaged by that situation
at this point in time.
In a similar vein, Ms Justine Caines of Homebirth Australia stated:
Homebirth remains the only service in this country that is
not afforded appropriate professional indemnity insurance. Therefore, that is
obviously a double whammy as midwives do not have appropriate professional
protection and homebirth consumers are the only women in Australia who do not
have protection should negligence of that support be proven—and, when we are
looking at lifelong care in the worst case scenario of a disabled child, that
is considerable. So we are coming from a position of considerable disadvantage.
The committee notes that due to AHPRA's failure to effectively
administer practitioner registration, in some instances, practitioners have
unknowingly practised without being registered, as AHPRA also failed to notify
these practitioners that they had been deregistered. The committee is dismayed
that practitioners have been exposed to possible legal liability as a result of
AHPRA's administrative incompetence. Not only does this situation put
practitioners and their practices/employers at risk, it also puts patients at
risk, and the committee considers this an unacceptable situation.
The committee acknowledges the undertakings by professional indemnity
insurers to cover practitioners for the period in which they were practicing
while deregistered through no fault of their own. However, the committee is
aware that no such case has yet been tested, and remains uneasy as to whether
practitioners will be sufficiently protected in such a circumstance.
Further, the committee is concerned that there may be other, as yet
unidentified, legal implications arising from AHPRA's poor administration and
Impact on patients and health service provision
The committee heard that the issues with registration and the resulting
effect on the time and workload of practitioners have also led to impacts on
Hospitals were not obviously permitting practitioners who
were visibly unregistered on the record to practice or perform procedures, so
they had to be abandoned and rescheduled. Treatment of patients was delayed.
Case study 4.4
A nurse practitioner candidate commenced a series of
education programs for the community on the role of the remote nurse
practitioner in anticipation of registration as a nurse practitioner. As this
candidate's registration is now in the 5th month of processing, the community
is losing faith that the role will come to fruition. This candidate perceives
that the general community attitude has become one of remote communities again
missing out on access to an increased range of health care services.
College of Nursing, Submission 62, p. 2.
The impact this can have on both practitioners and their patients was
illustrated by the RACGP, who informed the committee that about half a dozen of
its members had been deregistered:
They were informed after the date had elapsed that they were
no longer registered and they had to go back and reapply for their
registration, have a police check et cetera, and that created a situation where
they were effectively unable to work in their practices for several weeks...As
a small business person, when you are unable to make an income, there are significant
financial imposts. It was a very major issue for our members, particularly
elderly patients who were relying on the relationship they had with their
general practitioner and the ongoing knowledge of their biopsychosocial health.
Dr Hambleton described the impact that deregistration of a practitioner
can have on patients:
It is worrying for the patients. Alternative arrangements
need to be made for their treatment. And it is confusing for patients about why
their doctor cannot treat them.
The Australian College of Rural and Remote Medicine noted that the
registration delays have exacerbated long waiting periods for patients in rural
and remote communities:
The registration delays also adversely impacted patients who
had no choice but to seek alternative medical care, and or wait longer for
their consultations. Most of these patients would have already waited for
relatively long periods for their appointment due to existing workforce
shortages in rural and remote areas.
Rural Workforce Agency Victoria emphasised that such delays can impact
on the provision of health services to the community, particularly those more
Delays are both socially economically and costly to the communities
and patients. This compromises the sustainability of fundamental health services
to communities of high health need.
Mr Stokes further explained to the committee that the registration
issues regarding practitioners had deleterious impact on clients:
Above all, it was the impact on clients in the community that
was most significant from our perspective. Although it was very distressing for
our members and for registrants, the impact on the continuity of care and on
some of the most vulnerable members of the community was a serious consequence
of this disruption.
The APA further noted that the time that practitioners had to invest in
following up issues with their registration also had implications for patient
The head of the department spent a lot of time chasing up
registration problems, as clinician certificates were needed for
reaccreditation purposes for the hospital department. They did not cancel the
patients in this instance, but the head of the department said that
administrative issues with AHPRA took up significant amounts of time for nearly
all of the physiotherapists in the department and therefore that could not be
dedicated to patient care.
Dr Hambleton, AMA, elucidated:
Far from reducing red tape, the introduction of the national
registration scheme has in fact diverted considerable health care delivery
hours away from direct patient care. Thousands of doctors and other health
practitioners, and large number of health care providers such as hospitals and
member organisations like the AMA have spent countless hours and administrative
resources dealing with individual and generic problems with registration.
The committee points to the impact on patients and health service
provision as yet another example of the serious implications of AHPRA's
administrative failures. The committee notes that it has exacerbated patient
waiting times, and compromised health service provision, particularly in rural
and remote communities which are already particularly vulnerable.
Ramsay Health Care Australia explained to the committee that access to a
skilled workforce in adequate numbers is central to the provision of health
Ramsay Health Care holds the view that excellent patient
safety outcomes are inextricably linked to effective and efficient regulation
and registration of health care practitioners alongside excellence in clinical
governance and leadership. Our single greatest challenge in terms of delivering
high quality care (regardless of sector and/or service) is to ensure that we
can ensure access to a sufficient supply of skilled and regulated
The RACGP informed the committee that 700 doctors nationally across all
medical colleges (not just general practitioners) have not re-registered, and a
series of practitioners have become deregistered, leading to decreased
This has caused significant concern about the current 'very thin workforce'.
Professor Jackson elaborated:
We know that 700 doctors nationally have not reregistered. We
assume they are retiring but in general practice we need every single person on
deck to be able to deliver the high quality services we have traditionally
delivered to 90 per cent of our population every year. We cannot afford another
year like this last year, or doctors will not reregister and they will just go
into early retirement. I do not believe our workforce, particularly in rural
and remote areas, will recover.
Dr Hambleton further explained that any disincentive to re-register
could risk the loss of experienced practitioners who are valuable resources for
training and teaching:
Anything that puts a hurdle in front of people who have the
option of stopping work creates a potential risk that they will not come back
into the workforce. These are people at the end of their careers and we know
that our senior practitioners are excellent resources for teaching and
excellent resources for training. This is happening at a time when we need
those resources to build up the numbers in the professions. If we lose them and
they are deregistered and not available—doing something else—it is a tragedy
The ANF further noted that while the challenge of enabling and
encouraging people to re-enter the profession is ongoing, the current
registration processes are causing delays which 'have quite a profound impact
on those clinicians'. Ms Julianne Bryce of the ANF explained:
...certainly we continue to have frustrations around enabling
people to work who are well able to and being able to demonstrate that and to
facilitate that process so that they do not choose to work in another profession
because they cannot come back into nursing...some of our most senior
clinicians, our nurse practitioners, who are candidates and completed and who
are ready to be endorsed as a nurse practitioner but the processes are holding
However, the ANF did comment that ultimately the NRAS will help increase
re-entry levels for the profession:
In fact, the National Registration and Accreditation Scheme
will assist people re-entering the nursing and midwifery field in that
previously there were only a small number of programs that people could do to
enable them to re-enter the nursing and midwifery workforce. So we have had
instances where people, for example from South Australia, might have been able
to do a course only through Queensland. They had to register in Queensland, not
in South Australia, and so when they wanted to work in South Australia, their
home state, they had to re-register in South Australia as well, whereas now
they will be able to register nationally. The other component that I want to mention
is that the programs for re-entry will be accredited under national
accreditation, so that will also assist people re-entering the field.
Catholic Health Australia submitted evidence of significant delays in
registering new graduates – in some cases up to three months. During this
period the graduates were unable to work. New graduates indicated that given
the problems being experienced with registration, they had decided to delay the
commencement of their graduate program by several weeks. The fact that in some
instances new graduates were 'not being registered until a couple of days prior
to their commencement date with the facility' caused significant problems for
the hospitals employing those graduates:
This caused a great deal of anxiety and stress to the new
graduates, but also to the organisation as rosters were done around the fact
that they were starting on a certain date.
Submitters informed the committee that employers found themselves
supporting employees who were unregistered and unable to work. Ramsay Health Care
Australia told the committee that it provided new graduates awaiting
registration alternative employment as assistants in nursing or patient care
attendants so that they were able to earn an income, even if it was at a lower
rate – this equated to 8,000 hours (or round 1000 shifts) of employment. Health
service providers were further impacted by the delays in registration:
The delays in rostering graduates had flow on effects such as
the postponement of graduate programs, rostering and staffing implications and
loss of income for those awaiting registration.
Ms Spaull quantified the effect of the registration issues on work
hours, and the implications this had:
...we know that we had around 5,500 productive hours lost on
average to these periods of not being registered. Those shifts, which are hard
enough to fill, were then filled with either overtime or goodwill from our
existing permanent staff, from agency staff or from casual pooled nurses that
would work extra shifts.
Further, Mr O'Meara explained to the committee that delays in the
registration process also affects recruitment timeframes:
...there is a workforce shortage and a skill shortage. That
will get worse. The lead time for us bringing key staff from overseas, because
we just do not have enough in this country, can be nine months or 12 months. We
just had teams of people in the UK and Ireland recruiting for expansions in
hospitals in Western Australia that will be coming online between 15 and 18
months out. We have won the tender for a hospital on the Sunshine Coast which
will come online sometime near the end of 2013. We will start that process...certainly
no later than the end of this year or the beginning of next year. This is
because it is not just the migration time. The immigration process is quite
quick. The registration processing does take a significant amount of time.
Similar issues were raised by Catholic Health Australia's members, who
noted the difficulties that registration delays cause in terms of recruiting
staff from overseas:
There are difficulties with the time frame it will apparently
take to register specialist mental health nurses that have been recruited from
the UK and Canada. The recruitment firm report it will take 6 months to
register new recruits. One particular facility is in urgent need of these staff
due to the difficulty of recruiting Australian nurses to these roles.
These concerns were echoed by the Rural Health Workforce Australia, who
noted that administrative issues have the potential to particularly affect the
workforce in rural and remote communities:
Government is investing huge amounts of money into the
recruitment and retention of International Medical Graduates to provide a
service to areas of our country where Australian graduates don’t seem to be
keen in working. Rather than put up barriers to this group of people who play a
major role in looking after the health and wellbeing of our rural communities
we could make them feel valued and make the “process” welcoming while retaining
Currently this valuable workforce are required to provide
duplicate information to a number of bodies (the information provided to the
AMC is then required by AHPRA –
to what purpose?). Mostly the various players including AHPRA, registering
bodies, specialist colleges and PESCI providers are blissfully unaware of the
financial and personal costs incurred by doctors coming to work in Australia.
Many of them have to work for years or borrow from family to save to undertake
the AMC, English Language tests and PESCI interviews. To compete against other
countries we must get better at these processes.
This was supported by the AMA who submitted that any disincentive to the
recruitment of international medical graduates would particularly impact on the
health workforce in rural and regional communities:
Poor response times and lack of assistance and advice by
AHPRA have greatly impacted on International Medical Graduates (IMGs) who are
offshore and attempting to register for the first time with the Medical Board
of Australia. IMGs are particularly important to the medical workforce in the
less populated and more remote areas. Delays in registration of IMGs have a
direct impact on access to medical services by rural and remote communities.
The Australian Doctors Trained Overseas Association noted that a large
part of Australia's medical workforce are international medical graduates:
International Medical Graduates (IMGs) currently make up the backbone
of the medical workforce in rural and remote regions of Australia.
Approximately one-third of the Medical workforce in Australia, and up to 50% of
the doctors in rural and remote areas, are IMGs. In the past year there has
been a mass de-registration of IMGs as a result of AHPRA policies/decisions which
has affected tens of thousands of patients living in rural areas.
The Melbourne Medical Deputising Service noted that Australia's reliance
on international medical graduates is unlikely to decrease going forward, as
workforce shortages are project to continue:
There is little on the horizon to indicate that workforce
shortages will ease in the future – certainly not in the provision of
after-hours care. The latest MABEL Survey Report found that GPs are no longer
able to provide the after-hours service themselves:
Around 50% of doctors would like to reduce their working hours.
Around a quarter of all doctors are very or moderately
dissatisfied with their hours of work.
The first wave of the study’s data collection completed in 2008
found that nearly 12% of the GP workforce was expected to retire within five
years (MO, 1 May 2009).
Intentions to quit are largely driven by those over 55 years old
who expect to retire, and thus reflects the loss to the workforce of the 'baby
Rural Health Workforce Australia further noted that AHPRA's inability to
provide a timeframe for processing registrations creates significant difficulty
for employing practices and for practitioners. For employing practices this
uncertainty surrounding practitioner registration can hamper preparations for
the arrival of new doctors, particularly plans for the arrival of doctors from
overseas. It also hinders international medical graduate candidates in their
plans to depart their home country and in planning their arrival in Australia.
Rural Health Workforce Australia further submitted:
The delayed arrival of a doctor in to a rural community
places a strain on other medical and health practitioners in the town as they
carry the burden until the arrival of the new doctqor.
The committee was informed of the timeframes for registration, and how
this can impact on recruitment:
The processing time for general registration is currently 6
weeks and limited (Area of Need) is currently taking up to 3 months. In
addition, other agencies such as Medicare require one month to process provider
numbers and DoHA require one month to process a 19AB Exemption, an application
can sometimes take 5 to 6 months to gain approval. This often results in
practices losing a candidate and potential recruitment opportunities being lost
to rural general practice and communities of high health need.
Rural Workforce Agency Victoria emphasised that such delays can impact
on the health workforce, particularly in those more remote communities:
Delays can result in practices losing potential recruitments
and/or practices withdrawing offers of employment due to the length of time it
takes the candidate to obtain medical registration. Such delays can deter
potential candidates thus undermining the intention of the legislation to
ensure workforce mobility and flexibility. Communities of need such as rural, remote
and aboriginal communities with workforce shortages are very reliant on the recruitment
of GPs, especially IMGs.
Case study 4.5
Dr A – UK graduate experienced 6 month delay with
registration (initial application provided to AHPRA pre July 2010). During this
time AHPRA did not respond to emails or telephone calls in relation to this
matter. Dr A was extremely anxious during this time and the AWRGPN and Practice
employing Dr A remained in constant contact with the Dr to appease and ensure
interest in relocating to Australia. The Practice was forced to close books at
the Practice due to the delay in the registration application process and the
pressure on existing GPs.
Source: Albury Wodonga Regional GP Network (AWRGPN), Submission 30,
In summary Rural Workforce Agency Victoria (RWAV) submitted that:
RWAV is concerned that a lack of a robust national approach,
serious and significant administrative delays, poor communication and undue
barriers to registration have impacted on the medical workforce and Australia’s
ability to recruit and place medical practitioners. We are also concerned that
this will continue to compromise Australia’s reputation as a destination of
choice and hinder Australia’s ability to attract crucially needed qualified medical
practitioners particularly in relation to rural and remote areas of need, in a
globally competitive market.
The committee is concerned about the implications of registration
difficulties on the health workforce in Australia. In particular, these
difficulties appear to be hampering the employment of qualified practitioners
from overseas as well as making it difficult to retain and facilitate the re-entry
of currently qualified domestic practitioners. The committee acknowledges the
concerns raised in the evidence provided to the committee regarding the impact
any decline in the health workforce may have on health service provision in
Australia. This is a serious matter and goes to the heart of the purpose for
which AHPRA was established.
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