Chapter 4

Effect of implementation difficulties on health practitioners

Introduction

4.1        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.

4.2        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 commented:

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 Health Professional.[1]

4.3        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.[2]

4.4        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.[3]

4.5        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:[4]

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.[5]

4.6        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.[6]

Quantifying the impact

4.7        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 registration renewal;[7]
• MDA National Insurance: 15‑20 of their members approached them directly about registration issues;[8]
• 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 the 20s';[9]
• 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; [10]
• 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 from AHPRA;[11]
• 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;[12]
• 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;[13] and
• Australian Association of Psychologists (AAP): 570 psychologists were deregistered in Victoria and 130 were deregistered in Queensland.[14]

4.8        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 than others.[15] 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 problematic.[16]

4.9        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.[17]

4.10      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 is unprecedented.[18] 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 unparalleled proportions.[19]

4.11      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.[20]

4.12      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.[21] 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...[22]

4.13      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.[23]

4.14      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'.[24]

4.15      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 period only'.[25] 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.[26]

Committee comment

4.16      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

4.17      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.[27]

4.18      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.[28] 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.[29]

4.19      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.[30] 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.[31]

4.20      The AMA submitted that in their view, it is unacceptable the AHPRA's poor administration and processes have had such devastating impacts on practitioners:

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.[32]

4.21      A number of witnesses told the committee that a significant issue has been the deregistration of practitioners without notification.[33] 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.[34] 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.[35]

4.22      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.[36]

Case study 4.1

I 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.

4.23      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 confirmed:

...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 affected.[37]

4.24      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.[38]

4.25      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 unanswered.[39]

4.26      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 professional bodies'.[40] 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.[41]

4.27      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.[42]

4.28      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'.[43]

4.29      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.[44]

4.30      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.[45]

Impact on practitioners' reputation

4.31      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.[46]

4.32      MDA National Insurance informed the committee that five of their members had been deregistered, and all but one have now been successfully re-registered.[47] Dr Hambleton described the impact that deregistration can have on a practitioner:

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.[48]

4.33      The committee received evidence that physiotherapists also had concerns about how their deregistration by AHPRA had affected their reputation as practitioners:

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.[49]

4.34      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 anyone.[50]

4.35      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.[51]

Committee comment

4.36      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

4.37      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.

4.38      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.[52] The evidence provided by MDA National Insurance supported these comments, and further stated:

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.[53]

4.39      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. [54]

4.40      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.[55]

4.41      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.[56]

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 conditions.

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.

Source: Avant Mutual Group, Submission 12, pp 5–6.

4.42      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.[57]

4.43      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.[58]

4.44      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'.[59]

4.45      Ms Wett, PSA, explained that the delays in processing registration applications and renewals has had considerable impact on both pharmacists and intern pharmacists:

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.[60]

4.46      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 of that.[61]

4.47      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.[62]

4.48      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'.[63]

Cost of registration

4.49      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 like that.[64]

4.50      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.[65]

4.51      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.[66]

4.52      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.[67]

Committee comment

4.53      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.

4.54      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.

4.55      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.

4.56      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

4.57      The committee received evidence that the deregistration of practitioners also affects the ability of patients to claim Medicare benefits.[68] 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 unregistered.[69]

4.58      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 rebates:

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.[70]

4.59      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.[71]

4.60      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.[72]

4.61      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'.[73] 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.[74]

4.62      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.[75]

4.63      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 provider number:

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.[76]

4.64      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.[77]

4.65      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 payments:[78]

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.[79]

4.66      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.[80] 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'.[81] 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 benefits'.[82]

4.67      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.[83]

4.68      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.[84]

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 Medicare.

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.

Source: Dr Sandra Gaffney, Submission 210, pp 3–5.

4.69      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.[85]

4.70      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.[86]

Committee comment

4.71      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.

4.72      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

4.73      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.[87] 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.[88]

4.74      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 practice.[89]

4.75      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.[90]

4.76      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 decision.[91]

4.77      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.[92]

4.78      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.[93]

4.79      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'.[94] 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.[95]

4.80      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.[96]

4.81      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.[97]

4.82      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.[98]

4.83      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 expiry date.[99]

4.84      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.[100]

4.85      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.[101]

Committee comment

4.86      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.

4.87      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.

4.88      Further, the committee is concerned that there may be other, as yet unidentified, legal implications arising from AHPRA's poor administration and processes.

Impact on patients and health service provision

4.89      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 patients:

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.[102]

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.

Source: Royal College of Nursing, Submission 62, p. 2.

4.90      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.[103]

4.91      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.[104]

4.92      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.[105]

4.93      Rural Workforce Agency Victoria emphasised that such delays can impact on the provision of health services to the community, particularly those more remote communities:

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.[106]

4.94      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.[107]

4.95      The APA further noted that the time that practitioners had to invest in following up issues with their registration also had implications for patient care:

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.[108]

4.96      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.[109]

Committee comment

4.97      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.

Workforce issues

4.98      Ramsay Health Care Australia explained to the committee that access to a skilled workforce in adequate numbers is central to the provision of health care:

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 professionals.[110]

4.99      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 workforce capacity.[111] 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.[112]

4.100         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 going forward.[113]

4.101         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 them up.[114]

4.102         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.[115]

4.103         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.[116]

4.104         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.[117]

4.105         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.[118]

4.106         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.[119]

4.107         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.[120]

4.108         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 its rigour.

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.[121]

4.109         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.[122]

4.110         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.[123]

4.111         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 boomer' generation.[124]

4.112         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.[125]

4.113         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.[126]

4.114         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.[127]

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, pp 1‑2.

4.115         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.[128]

Committee comment

4.116         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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