Related matters raised during the inquiry
A number of related matters were raised in during the inquiry. These
went to the issue of accountability of the Australian Health Practitioner
Regulation Agency (AHPRA), mandatory reporting requirements, the registration
of overseas health practitioners and the registration of senior doctors and
academic health practitioners.
Comments on complaints handling went to two areas: complaints about
AHPRA itself; and the handling of complaints about health practitioners.
Complaints about AHPRA
Submitters commented that there were difficulties in attempting to
complain to AHPRA.
Many practitioners contacted the National Health Practitioner Ombudsman and
Privacy Commissioner (NHPOPC). However, submitters commented on the
difficulties of contacting the NHPOPC and the lack of resources of that office
to deal with the number of complaints received.
The Australian Health Workforce Ministerial Council (AHWMC) commented
that there was concern about AHPRA's handling of complaints about its
operations. AHWMC stated:
The scale of the issue was evident from the number of
contacts made with the National Health Practitioner Ombudsman Privacy
Commissioner (NHPOPC). Many of the issues raised would, under normal
circumstances have been expected to have been resolved by AHPRA in the first
instance. However, as a result of frustration on the part of registrants and
employers unable to make contact or get satisfactory responses from AHPRA
callers resorted to making contact with the NHPOPC. An indication of the
improvement in AHPRA operating in this area is the significant decreases in
calls to the NHPOPC in recent months about not being able to contact AHPRA.
Complaints about health
The AHWMC commented that a significant role for AHPRA is the management
of notifications to boards regarding registrant health, conduct or performance.
AHPRA inherited all open notifications and disciplinary matters from state and
territory boards (other than NSW) at 1 July 2010. AHPRA is currently managing
approximately 3000 notifications, including those received since 1 July 2010.
The Australian Dental Association (ADA) pointed to a number of
difficulties being experienced with the complaints process:
right to respond to a complaint: there are inconsistencies
between jurisdictions as to the right to respond to a complaint by a patient;
response times in the preliminary assessment phase: the response
times vary across the jurisdictions from 14 days to 28 days;
provision of information: the level of information provided to
the health practitioner who is the subject of a claim varies from only the name
of the complainant or notifier to additional essential information; and
notification form: the form is prescriptive and 'may lead a
notifier to make choices which are not reflective of their actual concerns'.
The Australian Medical Association (AMA) commented on the need for
consistency in complaint handling and the importance of having appropriate
complaint handling processes in place. The AMA stated:
It is vital that the State AHPRA offices, in conjunction with
the State Medical Boards, have clear and documented operating protocols to
ensure that complaints about medical practitioners are dealt with consistently
around the country. As yet, we are not aware that these protocols have been
written. They should be drafted and made available for public consultation
before being finalised.
The importance of operating protocols is highlighted by
recent matters where the AMA has evidence of administrative and bureaucratic
methods significantly interfering with the normal rights of persons. We also
believe that some complaints could have been resolved simply and more efficiently,
but have instead been drawn out at the expense of the registrant and AHPRA
Avant Mutual Group commented that in its view, the complaint handling
processes are working well and the processing of complaints appear to be taking
no longer, and is often much quicker, than the time taken for processing
complaints by some of the previous state boards. However, Avant Mutual Group stated
that there is concern that the approaches to complaint handling are not
consistent nationally, in particular 'the willingness of some state boards/AHPRA
to accept and act on notifications'. Avant Mutual Group voiced concerns that
some notifications are generated in other than good faith. However, AHPRA seems
to be unwilling to consider the issue of good faith. Avant Mutual Group provided
the following case:
In Queensland AHPRA has given a medical practitioner a notice
of its intention to impose onerous and restrictive conditions on the doctor's
practice because a current competitor of the doctor (for whom the doctor
receiving the notice had once worked), had made a complaint suggesting the
doctor was not competent to practice. The time given for the doctor to respond
to the notice to show cause was very short. There was no supporting material
provided with the complaint. After Avant became involved and senior
practitioners had assessed the doctor in question, it was clear that the doctor
was competent to practice. However, the expense required to respond to this complaint,
which appeared to be based on anti-competitive issues, was significant.
Avant Mutual Group also noted that other complaints have been made by
ex-spouses of doctors during family break-ups and anonymously. Avant concluded
'the necessity for AHPRA to be take care in accepting and acting on such complaints
including using its emergency powers as set out under section 156, needs to be
The committee received a large number of submissions in relation to
complaints against privately practising midwives. Homebirth Australia commented
that 'the handling of those complaints by AHPRA are of grave concern'.
It was submitted that there are individual cases where a midwife has been
suspended or had substantial limitations placed on their professional practice
pending an investigation of their conduct. The Australian Society of
Independent Midwives (ASIM) commented:
ASIM is aware of a number of individual cases where a midwife
has been suspended or had substantial limitations placed on her professional
practice pending an investigation into her conduct. ASIM submits that taking
such steps before a matter is finalised is a very serious matter and has the potential
to destroy a midwife's livelihood. As the National Law recognises, such a step
should only be taken when the practitioner poses a serious risk to persons and
it is necessary to take immediate action to protect public health or safety.
When taking such a serious step it is imperative in the interests of natural
justice that the complaint then be dealt with in an expeditious manner. ASIM is
aware however of at least one case where a midwife has been suspended pending
the investigation of her matter for nearly 11 months. This is simply
It was also argued that the complaint handling processes regarding
self-employed midwives are different to those which apply to medical
practitioners or nurses. Ms Justine Caines, Homebirth Australia commented:
We have one midwife who has had a complaint that is not by
the current family or any person that is being cared for by her. It is by some
third party. It is not based on and does not represent hospital notes that have
been gathered. She was then relegated instantly to hospital-based practice, she
has lost her livelihood and her clients have lost their care provider. I spoke
to a director of obstetrics at a tertiary hospital in Sydney who has 27 years
experience, and I said to him, 'In your experience, has this happened to an
obstetrician in 27 years?' He said no. He said that the only case he knew of
was after five complaints of a registrar made in quick succession; they then
took out a management plan and that registrar was put under some sort of
supervised practice. However, with homebirth midwives, across virtually every
state, we are seeing a considerably different bar.
The Australian Private Midwives Association provided further evidence in
relation to this matter, noting that even if a previous complaint, of which a
midwife has been absolved, is on the midwife's record, they are prevented from
...where complaints have already occurred with a midwife's
registration, be it 10 or 15 years ago or whenever it might have been, that
triggers a process when they go to reregister, which prevents them from
actually reregistering. Even if the complaint had been dealt with and put to
the side and they were exonerated, they are still unable to complete a re-registration
process. That creates significant difficulty.
The committee is concerned that AHPRA's complaints handling processes
were so inefficient that practitioners had no recourse but to refer matters to
the Ombudsman even for matters so trivial as to find a contact number for AHPRA
staff. The committee considers that a national organisation should have the
highest standards and efficient processes for dealing with complaints.
In relation to complaints about practitioners, the committee was
provided with many examples of timeframes for resolution of complaints which
were not reasonable. The committee notes that complaints are dealt with by the
relevant board. However, the administration of complaints is undertaken by
AHPRA (except in NSW). The committee is concerned about inconsistency in the application
of complaint processes, the prescriptiveness of the application form and the
way in which vexatious complaints are handled. The committee considers that
further development of the complaints process is urgently required.
The issue of accountability of AHPRA was raised in two areas: first,
accountability to the Parliament and secondly, accountability to health
The Council of Australian Governments (COAG) agreed to the provision of
$19.8 million with for $12.5 million for practitioner regulation and $7.5
million for accreditation reform. The Commonwealth Government contributed $9.9
million (50 per cent of the total) which reflected the established Australian
Health Ministers Advisory Council cost sharing principles.
The Australian Health Workforce Ministerial Council (AHWMC) is responsible for
the oversight of the implementation of the National Registration and
Accreditation Scheme (NRAS).
The Australian Health Workforce Ministerial Council was established under
the Health Practitioner Regulation (Administrative Arrangements) National
Law Act 2008 following signing of, and based on, the agreement between
First Ministers to the COAG Intergovernmental Agreement (IGA) for a National
Registration and Accreditation Scheme for the health professions (ref. IGA Item
7). The functions of the AHWMC are also outlined in the National Law sections
11–15 of Part 2. The Department of Health and Ageing stated that 'the
Ministerial Council consists of the Commonwealth, State and Territory Health ministers
who remain accountable to their respective Governments'.
Ms Kerry Flanagan, Acting Deputy Secretary, Department of Health and
Ageing, explained that policy advice is provided to AHWMC by the chief
executive officers of the health departments. Further, a committee of officials
was set up when the NRAS was established. Ms Flanagan went on to note:
That still exists; it has different membership but it is made
up of officials of all jurisdictions in terms of providing policy advice. I
would just like to clarify though that the role of the ministerial council...it
has an ongoing and defined role but had not intended or expect to continue
administrative involvement except as a very light touch. So under the national
law ministers are responsible for approving registration and accreditation
standards put forward by the national boards, approval of specialist
registration and approval of areas of practice for the purposes of endorsement.
Ministers can only give directions to national boards or the national agency
under limited circumstances specified in the legislation. So I just want to be
clear that when you talk about policy, I suppose the role of this particular
council in these arrangements is set out in the legislation itself.
AHPRA provides its annual report to the relevant minister in each of the
jurisdictions, including the Commonwealth, for presentation to their respective
Parliaments. AHPRA also indicated that communication with the responsible minister
in each state and territory occurs as required and primarily involves the
relevant state or territory manager for AHPRA and issues of relevance to the
AHWMC has monitored the implementation process and in February 2011,
AHWMC met to discuss issues arising from the move to the NRAS. The Department
of Health and Ageing commented that:
...the workforce ministerial council discussed the issues
that were being raised by the professions in February...It agreed to have an
increased monitoring role over AHPRA and that AHPRA needed to report more
closely. It appointed the CEO of the Victorian Department of Health, Fran
Thorn, to work with AHPRA to resolve the problems. All ministers agreed that
they would make a commitment to seeing what support they could provide to AHPRA
through this start-up period.
Some submitters pointed out that under the old system, registration was
handled by state or territory boards directly accountable to the health
minister. However, under the NRAS, the system is much more complex and unclear.
Mr Stephen Milgate, Executive Director, Australian Doctors' Fund,
commented that 'there is no one particular minister or public servant who we
can actually approach who had any authority to really control the process'.
Mr Milgate went on to state:
Our major focus of concern is the non-accountability to a
legislature of this entire process. We are appealing to all parliamentarians.
This has been created outside of the legislative process and outside direct
Mr Milgate concluded that :
...we do not believe that any parliamentarian, of any
political party in this country, wants an unaccountable organisation running
500,000 health professionals which is unreachable, has nine bosses and is
virtually unaccountable by design. We do not believe that is in the national
interest...But our essential concern is for public safety, the national
interest and the rights of legislatures to hold people accountable for their
In relation to accountability to the professions within the NRAS, the
committee received many comments about the lack of transparency of AHPRA and the
lack of consultation with the professions about problems during the
implementation phase as well as concerns about the lack of accountability for
the accreditation issues.
In relation to AHPRA, Ms Liesel Wett, Chief Executive Officer, Pharmaceutical
Society of Australia, commented:
Ultimately we would like to see greater transparency and
consistency in registration processes and other activities which directly
affect health practitioners and the services they then provide to the
community; effective and timely responses to queries and in the processing of
applications; and better communication with health practitioners as well as
stakeholder organisations such as ours.
Dr Mukesh Haikerwal raised concerns with section 236 of the National law
and its effect on accountability. Section 236 shifts liability from people
working for or on behalf of AHPRA, known as 'protected persons', to AHPRA
itself. Dr Haikerwal's concern was that the practical exercise of s236 will
hinder accountability as 'this suggests no accountability for the work or how
it is done'.
Dr Haikerwal was further concerned that the ministerial accountability
arrangements were also unclear.
In relation to accountability of the boards set up under the NRAS, the
Australian Psychological Society (APS) commented:
It is of concern that the new registration process appears to
be dictated by the National Board without due consideration of the practical
consequences to health practitioners. "Continuous development of a
flexible, responsive and sustainable Australian health workforce" has
in our experience, not been contemplated in the implementation of the National
Scheme. Nor does the operation of the National Scheme to date have any apparent
transparency or accountability.
The Australian College of Mental Health Nurses (ACMHN) suggested that
communications between nursing organisations and the National Nursing and
Midwifery Board did not meet the standard required under the National Law when
consulting on registration standards. For example, there appears to be no
mechanism to inform stakeholders that a consultation is taking place other than
publication on the website and 'usually this has been in association with
inappropriately short periods of time for consultation'.
The ACMHN went on to comment:
This type of process limits robust consultation, reduces
transparency of process and can inadvertently encourage bias.
However, the Australian Doctors Trained Overseas Association (ADTOA)
supported the new NRAS arrangements regarding accountability, and characterised
it as a 'significant improvement':
A significant improvement in the national scheme is that now
there are standards outlined in the National Law that are supposed to guide the
policies and actions of the professional boards regarding transparency,
accountability and fair due process. In addition the Board’s policies/action cannot
breach anti-discrimination law. This is a significant improvement over the
former system where there was little if no oversight of the separate Medical
Boards, and minimal avenues for meaningful input from the government and other
Yet this support was not without criticism. The ADTOA noted that in
order for international medical graduates, or IMGs, to challenge board actions
where the IMG believes the board has not followed its own policy, the IMG would
themselves need to pursue the matter through the courts:
This begs the question how can the Medical Board continue to
act in a manner that contravene the standards that are supposed to guide their
actions? Also how is it possible for AHPRA to be able to implement policies
that may be in breach of anti-discrimination law? Unfortunately the only way to
challenge potentially unlawful actions/policies is through legal channels. As
already mentioned, given the overwhelming costs involved, legal action is not a
realistic option for most IMGs.
Secondly, currently there is no mechanism in place to enforce
these standards, and/or make judgments as to whether these standards have, or
have not been met. This is a bit like having a speed limit but no speedometer
and no police available to enforce it!
AHPRA provided the following comments about accountability:
AHPRA and the National Boards are committed to transparency
and accountability in all their functions, as well as delivering high standards
of service. AHPRA, together with all National Boards, have adopted a Complaint
Handling Policy and Procedure (the Complaints Policy). This formalises a
process through which dissatisfied applicants and practitioners can have their
concerns about AHPRA or the National Boards fairly considered and addressed.
The Complaints Policy was developed to provide this mechanism and has been in
effect since 14 September 2010.
In order to improve accountability, health practitioner organisations
suggested that more formal arrangements be put in place to ensure appropriate
and timely consultation between AHPRA and organisations and between the
national boards and organisations. Mrs Elizabeth Foley, Federal
Professional Officer, Australian Nursing Federation (ANF), commented:
...the ANF wishes to take advantage of this inquiry to
recommend that AHPRA establish a formal and ongoing advisory committee of the
registered professions and soon to be registered groups. This committee would
essentially be an expansion of the existing professional reference group, of
which the ANF is a member, whose remit would include discussion of all issues
pertaining to the national registration and accreditation scheme.
The Australian College of Rural and Remote Medicine also called for
proactive mechanisms within AHPRA to manage and encourage meaningful
consultation, collaboration, communication and feedback about issues.
The Australian Physiotherapy Association (APA) also recommended that AHPRA
increase its levels of direct communication with the professional associations
through the Professions Reference Group (PRG). The APA noted that this group
had been convened when the problems with the renewals process were identified.
The APA recommended that AHPRA establish this group as a formal advisory
committee of the currently registered professions, and soon to be registered
professions, to discuss issues related to the administration of the NRAS.
The PRG has been an effective consultation and communication
forum for the registered professions and the continuation of the information
exchange within a formal advisory committee to the staff of AHPRA would be
valuable to all concerned. The APA believes that such a body would be
particularly relevant with the new professions coming into the AHPRA scheme
over the next year.
The Optometrists Association Australia proposed that AHWMC should
consider establishing a standing advisory group by which advice from the
professions regulated by AHPRA can be taken into consideration for the future
direction of the Agency and its dealing with the regulated professions.
The ACMHN recommended that consultation could be improved through the provision
of mechanisms through which consultation can take place, more information about
the consultations taking place, and more time for consultation.
The evidence received highlighted a significant lack of accountability
of AHPRA to the various jurisdictions and to the professions which will fund
the NRAS. The committee considers that AHPRA should establish professional
consultative groups. Such a mechanism would improve communications between
AHPRA and professional organisations and help to quickly identify shortcomings
in AHPRA processes.
Senior doctors and academics
A matter raised with the committee was the effect of the NRAS on senior
doctors and academics. In relation to senior doctors, the arrangements have now
changed, and any doctor retiring after the implementation of the new
arrangements is unable to retain limited prescribing and referral rights,
unlike doctors who retired before the new system was put in place. Professor
Claire Jackson, President, Royal Australian College of General Practitioners,
commented that there appeared to be no evidence why this change had been made
except because such a registration category had not been allowed in some jurisdictions
We believe that it is because in some states the legislation
was to allow retired doctors very limited prescribing and referral rights and
in others it was not, and so they removed the rights across the board. So we
have two classes of retired doctors now. There was absolutely no evidence that
the college could uncover, despite repeated requests, that there were any
dangers, or safety or other related issues, with these very, very limited
rights for retired doctors, for their family members only. So it was not an
evidence based decision. Finally, it is very expensive for these doctors to
remain in a practising category even if they are only doing occasional clinical
sessions. They have to undertake a full 130 QA and CPD points, professional
development points, per triennium, which will cost thousands of dollars. They
need to retain their registration at a significant level.
Professor Jackson went to comment that this was a loss to the
Most of our senior doctors have said to us that this is now
such a financial impost that, for the small amount of teaching and mentorship
they wish to continue doing, they will not be able to sustain it. These are the
giants of our profession. They have 40 years of clinical experience, which
often far outstrips the sort of experience we have with all the scanning pathology
and other issues available to us now, and we really, really want to strongly
remonstrate that we should review this decision, acknowledge there is no
evidence to it and reinstate these very senior, very experienced doctors to
support us in our profession going forward.
The Australian Doctors' Fund (ADF) also raised concerns in relation to
the difficulties faced by senior doctors, from 55 years of age and above,
who want to continue to work, but are unable to obtain an effective
classification to work and are therefore 'being forced out of the profession'.
Both the Medical Deans Australian and New Zealand and the Australian
Dental Association (ADA) commented on the registration of academic staff. The
Medical Deans noted that under the current regulations, doctors who contribute
on an occasional basis to the teaching of medical students outside a clinical
context are considered to be 'practising' under the interpretation of the
regulations and were subject initially to full registration fees. However,
after representations a voluntary agreement by the Medical Board of Australia (MBA)
saw the fee reduced to $125 for doctors undertaking only teaching or
examining/assessing. Further consultations by the MBA will look at the current
definition of 'practice' and make a recommendation to the Ministerial Council.
The ADA similarly pointed to the financial disincentives of full
registration fees for dental academic staff.
The committee is concerned that there is no flexibility for health
practitioners wishing to teach and mentor students or to practise in a limited
way. This will have a detrimental impact on academic institutions and the
health workforce. The committee therefore considers that greater flexibility in
the categories of registration is required and that the AHWMC should address
this matter urgently.
The National Law includes provisions for mandatory reporting of health
practitioners by another practitioner after forming a reasonable belief that
such conduct is 'notifiable'. Notifiable conduct includes practising while
intoxicated by alcohol or drugs; and placing the public at risk of substantial
harm because the practitioner has an impairment or the practitioner has
practised in a way that constitutes a significant departure from accepted professional
Concern was expressed that the mandatory notification requirements were
overly prescriptive and may prevent practitioners from seeking assistance.
The Royal Australian College of General Practitioners (RACGP), for example,
argued that the mandatory reporting requirements were 'likely to have the
opposite of the intended effect' in that health professionals would be more
likely to conceal their impairments from colleagues:
This will exacerbate the issues and drive them underground,
rather than decrease the risks to patients, the public, the practitioners
themselves, and their colleagues. Only the current system of collegiate support
and peer review can ensure that impairment issues will be dealt with in the
Dr Stanley Doumani, Australian Doctors' Fund, commented:
One of the things that I do is carry the phone for the ACT
Doctors' Health Advisory Service. I have noticed that since AHPRA and mandatory
reporting commenced, there has been a dramatic fall in the number of calls that
I have been getting. That troubles me because I worry about my colleagues not
seeking help when they need it.
Dr Mukesh Haikerwal also pointed to the requirement to notify conduct
which constitutes a 'significant departure from accepted professional
standards'. Dr Haikerwal argued that:
Combined with the subjective test intrinsic to the notion of
"reasonable belief", the threshold for the requirement of triggering
notification is low. It follows that the mandatory notification process is
potentially open to abuse by claims made in bad faith with the intention of
adversely affecting the registration status and the subsequent employability of
a health practitioner.
He went on to note that overseas trained practitioners were particularly
vulnerable to such claims. Dr Haikerwal argued that the National Law 'does not
offer any definition of reasonable belief or significant departure from
accepted standards of professional conduct'.
He also stated that there are penalties for an employer not reporting an
instance of notifiable conduct. Dr Haikerwal asserted that:
These new provisions promote a culture that resorts to peer
reporting for fear of legal repercussions...or as a method of filtering out
those practitioners struggling to gain integration and acceptance within the
profession or indeed another avenue for employers to act against an employee
without first initiating normal workplace processes.
Dr Haikerwal citied a case of mandatory notification where even though
the practitioner had been exonerated by AHPRA, 'there was no recognition [by
the agency] that this was a most distressing situation that needed to be handled
with care and sensitivity'. Dr Haikerwal summarised his view of AHPRA's conduct
in this particular case:
...the attitude has been high handed, officious, thoughtless,
unprofessional, unforgiving and the principles of natural justice, access to
common law rights, the presumption of innocence have been ignored. There is no
respect as the notion is one of absolute power which cannot be questioned. An
expectation that the high handed manner must be tolerated and there will be no
detractors for fear of retribution from the Agency.
Associate Professor Rait of MDA National Insurance also told the
committee of his concern about a situation where a practitioner under
psychiatric care was reported to AHPRA to be 'at risk' by the treating doctor.
It was believed that as a consequence of this, the practitioner took his own
life. Associate Professor Rait emphasised that the implications for the
therapeutic relationship under the mandatory obligations are clearly very
MDA National's submission noted the potential for vexatious complaints
under the current system and also pointed out that the mandatory reporting
provisions were not included in the legislation adopted by Western Australia:
We understand there are instances where the provisions have
been interpreted or implemented in such a way to disadvantage individuals to
the extent that there is potential that impaired doctors may have been
reluctant to self refer for help because of the risk of being reported to
AHPRA. We remain of the view that such is an unintended consequence of the
legislation and yet it remains to be addressed on a national basis and yet we
note that in Western Australia mandatory reporting of colleagues by treating
doctors has been removed.
Mr Boyd-Boland, ADA, suggested that an approach similar to that taken in
Western Australia would be preferable:
We are concerned that some of the mandatory reporting requirements
are preventing some practitioners from seeking assistance from other health
practitioners to deal with the potential for impairments. You may know that in
Western Australia the legislation there is slightly different and we have
sought to have that Western Australian variation adopted nationally.
The RACGP went further and recommended that the National Law should be
amended 'to exempt the health professional's treating doctor from mandatory
reporting under section 141 of the legislation'.
APS was particularly concerned about the impact of mandatory reporting
requirements on psychologists who provide services for the Family Court of
The APS Family Law and Psychology Interest Group made similar comments,
Psychologists who undertake assessments in family court
matters are routinely regularly reported to AHPRA following family court
This has been recognised internationally in family law to be
reflective of the nature of Family Law processes, and generally represent the
To invalidate the opinion of the clinician,
To use legal leverage by excluding the psychologist from future
court proceedings, and
To gain revenge and retribution on the psychologist when the
opinions expressed in reports do not favour them.
AHPRA fails to consider the particular professional,
financial and physical risks for psychologists specialising in Family Law and
the potential for competing responsibilities between their duty to the court
and current parameters for professional practice.
While not suggesting that Family Law psychologists be exempt from
complaints, it was suggested that AHPRA needed to change the way it handled the
We submit that there needs to be some mechanism where these complaints
are screened to avoid wasting time, energy and money in undertaking
investigations where the litigant obviously has malicious motives.
...AHPRA also routinely ignores the rights of other parties
and children involved in assessments. It is typical practice for AHPRA to rely
on the complainant's view without seeking input from the other party and to
demand files and reports without consideration for the other participants'
rights and our ethical and legal responsibilities to them.
The submission from Medical Deans Australia and New Zealand emphasised
that the mandatory notification obligations also apply to education providers
of medical students when it is suspected that a student's ill health may be
placing the public at risk. The Medical Deans considered that an appropriate
'feedback mechanism' needs to be put in place:
...back to the host education provider (i.e. the institution
that the student is enrolled at). The universities have a duty of care to its
[sic] students and Medical Deans feel it is imperative for universities to be
informed of any student reported to AHPRA to allow the university to be able to
offer appropriate support and care to that student.
The committee notes the issues raised in relation to the mandatory notification
requirements. This is a difficult area of regulation and the safety of the
Australian public must be paramount. However, the committee considers that
there is merit in examining the operation of the mandatory notification regime
in the National Law in comparison to that operating in Western Australia.
Overseas trained health practitioners
The committee received evidence of the difficulties experienced by
overseas health practitioners (mainly medical practitioners and nurses) seeking
registration in Australia. Some of these difficulties were similar to those
experienced by other health practitioners during the registration process
including inappropriate delays, inaccurate advice, and lost documentation. Rural
Health Workforce Australia commented that the delays and AHPRA's inability to
provide a timeframe for processing registrations, made it very difficult for
IMGs to plan their arrival in Australia and also made it difficult for
employing practices to plan. Such delays result in problems for both the
medical practice employing the IMG and for arrangements for supervision and
mentoring of the new doctor.
Case study 5.1
An overseas qualified nurse (Sweden) applied for
registration in October 2010 and was informed the assessment process could take
up to three months. The nurse continued to check on her application and was
informed in November that the application was straightforward and was in the
final stages. The nurse was told this several times, however in December was
informed that AHPRA had not started the application process (at this time AHPRA
indicated, assessment takes three months from when they start the process). The
nurse contacted the ANF (Victorian Branch) who subsequently contacted AHPRA to
be informed that overseas applications had been put on hold to deal with
domestic applications. The nurse received her registration on 21 March 2011,
six months after initial application.
Nursing Federation, Submission 57, p. 4.
The Melbourne Medical Deputising Service (MMDS) commented that when
dealing with AHPRA nothing has been forthcoming in the way of options or
possible solutions. MMDS commented that the delays may result in English tests
expiring requiring IMGs to go through the process as again. The same comments
were made in relation to Certificates of Good Standing required by
international health practitioners.
The Rural Workforce Agency Victoria commented that process time for general
registration is currently six weeks and limited (Area of Need) is currently
taking up to three months. There are also Medicare and Department of Health and
Ageing requirements which add to the time taken for IMGs to commence practice.
An application can take six to eight months to gain approval and the Agency
noted that by this time practices in rural areas may lose a candidate.
However, there were a range of matters particular to overseas trained
health practitioners which were brought to the committee's attention including
the new English test and changing registration requirements.
Avant Mutual Group commented that one of the issues facing IMGs who
arrived in Australia before 2007 has been the frequent changes in policy concerning
demonstration of competence. Initially, the only requirements were for the
practitioner to be supervised and for the supervisor to provide reports to the
relevant medical board about the international graduate. In 2007 a requirement
was introduced (in some jurisdictions) that IMGs pass particular Australian
qualifications within four years. In 2009 (in some jurisdictions) a requirement
was introduced that the IMGs had to demonstrate certain progress towards
passing the Australian qualification. Then at the end of 2009 at least one
jurisdiction introduced a requirement that IMGs sit the Structured Clinical
Interview (SCI) if they had not passed an Australian qualification.
Avant Mutual Group concluded that these changes made it very difficult
for many IMGs who had worked safely and competently in Australia for many
years, including in areas where Australian graduates would not work, believing
they met the relevant (pre-2007) requirements. However, the some IMGs are now
required to invest considerable additional time in order to comply with the frequent
changes post 2007. This often posed additional stresses on the doctors and
their families in adjusting to their new life in Australia.
The MMDS also commented on the difficulties facing IMGs and stated that
IMGs face a 'maze of complex information' with each step in the process long
and frustrating. The overall financial cost for IMGs is many thousands of
dollars and they do not understand why everything is so hard when dealing with
the relevant assessment and entry systems not the least of which is AHPRA.
Another example of problems was provided by Rural Health Workforce
Australia which noted that if an overseas trained doctor wishes to move from
one employer/location to another they are required to submit a new registration
application and fee in some jurisdictions, while in others they are only
required to submit a change of circumstances form. Rural Health Workforce
Australia concluded that this is 'yet another example is that the registration
processes are differing in lengths of time and are differing in cost across
The RACGP also noted that IMGs suffered particular consequences after
the new system was introduced, and those in Western Australia and Queensland
seemed to be most affected:
These are doctors who have been on temporary registration
arrangements and who, due to the new arrangements, very suddenly were informed
that they could not be re-registered because they had not completed their
fellowship. Fellowship exams occurs several times a year, and it did not give
them time to complete their fellowship prior to the cut off. So the college has
spent most of its effort around this issue working with the Medical Board of
Australia to try to support our international medical graduates—particularly
those in rural and remote areas, where they are 45 percent of the
workforce in both those states—to get through to their fellowship as quickly as
possible so that they do not miss out on registration.
The Royal Australian College of General Practitioners also commented on
the inconsistency of approach: in Queensland, IMGs are often subject to ongoing
progress requirements on their limited registration, whereby failure to meet
the progress requirements can result in refusal to renew the doctor's
registration. The RACGP stated that 'there are no such national requirements in
place, and inconsistent processes from state to state both contradict the
concept of national registration, and cause unnecessary difficulties for the
English language requirement
The new English language skills registration standard introduced with
the NRAS was canvassed in many submissions. The ANF for example, commented that
it had 'created enormous concern, confusion and distress for those
international students who had undertaken courses in Australia'. Of particular
concern was the change in rules so that students, who had incurred significant
cost in undertaking courses and who had expected to be registered at the
completion of the course, could not do so. The ANF stated that the situation was
'compounded by inconsistent information posted on the AHPRA website in the form
of the English language skills registration standard and the FAQs (frequently
asked questions) section'. The ANF also noted that not only overseas students
but also many Australian citizens, not having completed their secondary school
education in English, were also caught up in this 'debacle'.
The ANF considered that AHPRA was slow to respond to its concerns
regarding inconsistencies in the English language skills registration standard
and that although a review of the standard has been undertaken, AHPRA has
indicated that 'the current standard would remain in place despite the review
and that the outcome of the extensive consultation process remains pending'.
The ADTOA argued that there are two major concerns with the English
test. First, the standard of English expected of IMGs applying to work in
Australia is equivalent to what would be expected of a professor teaching in an
Australian university. In fact, according to a number of language instructors,
many native English speakers, including health professionals, would struggle to
pass the test. Secondly, the test results are only valid for two years even if
the IMG has been living and working in Australia.
The Medical Deans Australia and New Zealand commented on the English
test in relation to students from overseas who are university-trained in
Australia. The Deans were of the view that the regime is onerous for these
students, given that overseas students who graduate in Australia have already
faced several tests including stringent entry requirements for international
students into medicine (including rigorous English skills assessment undertaken
through the medical school admissions process) and the subsequent teaching and
assessment in English over a 4-6 year period of the medical program. Despite
the MBA partially addressing these concerns for students graduating in 2010 through
a 'one-off transition process', the Deans remain concerned that the underlying
problem caused by such an onerous condition remains. Consequently, 'in the
longer term Medical Deans believes these regulations should be eased
permanently for students undertaking their entire studies at an Australian
Pre-employment structured clinical
Pre-employment structured clinical interviews (PESCIs) were introduced
in 2008 as a tool to screen potential IMGs for their suitability for area of
need positions prior to starting work in Australia. The PESCI involves an oral
exam where candidates are asked questions about cases. Submitters voiced
concerns about the PESCI in relation to efficacy, timing and portability of
The ADTOA commented that the PESCI should not be used for registration
as this type of exam has shown to be difficult to standardise and is subject to
bias. ADTOA commented that
Despite the fact that the PESCI was never designed to be a
high stakes assessment, and the fact that it had not been properly standardized
on Australian trained doctors, AHPRA started to use the PESCI to assess IMGs
who were already working in Australia, some of whom had worked for as long as
25 years in this country. A large number of these IMGs failed the PESCI and
were subsequently de-registered.
The ADTOA pointed to problems with the PESCI including frequent rule
changes, procedural irregularities and inappropriate assessment, barriers to
meaningful appeal and changes to timetables without explanation.
The ADTOA recommended that an international health professional advisory and
advocacy committee be established. The committee would:
monitor the Professional Boards and other contracted
accreditation authority’s adherence to standards as outlined in the national
law including potential breaches of anti-discrimination law;
gather data and provide information about the impact of Medical
Board policies/decisions on IMGs as well as the potential impact on the Medical
workforce particularly on rural communities;
liaise with the Medical Board and other accreditation groups
(AMC, colleges) regarding any new policies that could potentially impact on
provide recommendations as to how to better support IMGs in the
provide information/advice/guidance to IMGs regarding registration/accreditation
provide some form of legal assistance/advice to IMGs regarding
MMDS also pointed to inconsistencies in the management and scheduling of
PESCIs and that there is inconsistency in the way PESCI providers ensure that
interview content is relevant. For example, the RACGP (SA) is an accredited
PESCI provider and the panel of assessors rightly require full information
(position description, support and supervision/mentor mechanisms) about the
position for which an IMG is being considered. However, this is not the case
for the Health Workforce Assessment Victoria which refuses any information
about the position or available support systems for which the doctor is being
considered. MMDS commented that differences in the way medical registration is
handled at the state level seems inconsistent with the intent of national
Case study 5.2
Only four applicants who were supported by the New
South Wales Rural Doctors Network (the RWA in NSW) undertook an AHPRA‐NSW PESCI in the 6 months from 1 July to 31 December
2010. These applicants waited an average of 6 weeks from lodging their PESCI
paperwork to being notified of the PESCI date. Applicants were given an average
of 2 weeks notice before the PESCI and more than 7 weeks (more accurately
between 4 and 13 weeks) to be advised of the outcome; even though they were
advised at the interview they will be notified within two weeks. Two other OTDs
supported by NSW RDN withdrew their applications for PESCIs in NSW, citing it
was too complex, frustrating and taking too long. The lack of enough sittings
of a PESCI panel in NSW over this time meant that RDN was very restricted in
the number of applicants it could support for registration.
Health Workforce Australia, Submission 49, p. 2.
MMDS also raised concerns about the PESCI waiting list in Victoria. MMDS
has referred to the Health Industry Ombudsman the case of one IMG who lodged an
application in August 2010 and who at 13 January was still 'some way down the
PESCI waiting list'. The doctor then applied to sit the test in South Australia
and did so in March 2011.
The Albury-Wodonga Regional GP Network commented that PESCI's for
limited registration doctors are non-transferrable between states contradicting
a national registration system. This was of particular concern and affected GPs
in the Albury-Wodonga region.
The committee notes that overseas trained practitioners form a crucial
part of the delivery of health services to Australians, particularly those in
rural and remote areas. The committee is therefore deeply concerned that
registration processes appear not to be applied consistently and that delays by
AHPRA have resulted in practitioners having to re-submit various certificates
and has adversely affected their ability to commence employment.
The committee concludes that this is an area where AHPRA must
significant improve its performance. Further, the committee considers that
updates on the registration of overseas trained practitioners should be
considered by the Australian Health Workforce Ministerial Council on a regular
basis. AHPRA should also establish a Key Performance Indicator on this category
of registration and report outcomes in its annual report.
Criminal history declaration
The registration process requires that health practitioners provide a
criminal history declaration. Evidence provided indicated a lack of flexibility
in AHPRA processes in implementing this requirement in addition to poor
The ANF, for example, provided two examples about the difficulties
experienced by their members in relation to the criminal history declaration:
a member who applied for registration as an EN in December 2010,
tried many times to contact AHPRA regarding the status of their application.
They were informed that AHPRA was waiting on a criminal history check (even
though the applicant had no criminal history) and that they were processing
hospital employed applicants before those working in aged care. The ANF
commented that this determination by AHPRA that one sector was more important
than another is not acceptable; and
a nurse member was contacted by AHPRA about non-disclosure of an
allegation of a criminal offence. The allegation occurred thirty years previously
and was dismissed in court. The nurse was told they had to provide a statutory
declaration as to why they did not disclose the allegation and a separate
statement of the circumstances of the case. The nurse was told they must
deliver these documents to the AHPRA office and that fax/emails were not
acceptable. The nurse lives in a rural area, which led to loss of income to
attend the AHPRA office.
While the committee is fully supportive of such a requirement, the
processes implemented by AHPRA in relation to this requirement have resulted in
difficulties in terms of inconsistency.
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