In response to one element of a 2005 Productivity Commission report , the Council of Australian Governments (COAG) decided that the state and territory systems of registration of health professionals, some in existence for over 150 years, would be replaced by a single national scheme . The new scheme, based on a “national law” adopted by all jurisdictions, is run by the Australian Health Practitioners Regulation Authority (AHPRA) which commenced operation in July 2010. It now covers 14 health professions and 600,000 health professionals. By the end of 2016, AHPRA will have been subject to two federal parliamentary inquiries (see here and here), one state parliamentary inquiry and an independent inquiry commissioned by the COAG Health Council. Such a record must lead to the question as to what is wrong with the scheme.
First, it is not truly a “national” scheme as NSW declined to join in, other than to participate in the national register. This has been euphemistically deemed a form of “co-regulation”. Three years later Queensland also opted to become “co-regulated”. The 2012 Victorian Parliamentary inquiry recommended that Victoria follow the same path.
The interim agency that designed and built the national scheme informed the health professions that the new scheme would bring efficiencies with cost savings and also claimed that the scheme would adopt best practices from the existing state and territory systems. Neither proved to be true as the annual renewal of registration fees for doctors rose by approximately 50% in Victoria in the first year of the system. In its first iteration, the draft national law omitted mention of funding for doctors health programs, an omission only amended after vigorous lobbying. Even now, nearly six years later, AHPRA’s allocation is inadequate to fund the best practice example of the comprehensive Victorian program for distressed doctors.
A recurring theme behind the four inquiries has been dissatisfaction from complainants, state health complaints commissioners and health professionals over the timeliness and fairness of the handling of complaints against health professionals. To quote from the most recent inquiry conducted for the COAG Health Council by Mr Kym Snowball :
“It was apparent from the outset of the Review that there is widespread concern about the manner in which notifications have been managed under the National Registration and Accreditation Scheme (the National Scheme). These views were repeatedly raised with the Independent Reviewer by members of the public, health practitioners, ombudsmen, jurisdictions and professions.”
The report then itemised nine separate concerns including:
“• delays in the preliminary assessment or investigation of concerns raised by notifiers
- delays in the finalisation of notifications
- poor communication with both notifiers and practitioners
- State and Territory Health Complaints Entities are generally not informed about the investigations and outcomes of cases handled by the National Boards and AHPRA
- perception of inconsistent investigative processes and outcomes among participating jurisdictions.”
It is noteworthy that the CEO of AHPRA has downplayed this strong criticism, as is exemplified in this exchange on Radio National in March this year. The Snowball report also identified the national scheme’s lack of accountability to individual health ministers in the respective states and territories.
In the absence of any detailed analysis as to why the scheme should be so strongly criticised, I offer the following possible explanations, together with suggestions for improvement. I believe that there are both structural flaws and legislative flaws in the scheme. The key structural flaws are the size of the bureaucracy that has been created and its consequent remoteness from the people it serves, its expensiveness (for little or no additional return) and the lack of direct responsibility to each state and territory health minister. The legislative flaws have been discussed elsewhere and, as they are only peripherally related to the overall problems with the national scheme, they are not detailed here.
The larger a bureaucracy, the more difficulty the general public and each health professional group will have in accessing its services and in obtaining information. Five years of experience of the mega bureaucracy that is AHPRA bears this out.
The lack of direct responsibility of each health minister is very evident when one compares the new national scheme with the system it replaced. Under the national scheme, any health minister with concerns must work through the COAG Health Council and AHPRA and then eventually the relevant national board (for doctors it is the Medical Board of Australia) and finally his or her relevant state board. Under the previous system, each state or territory medical board, nursing board and the like reported directly to the local health minister.
Similarly under the previous system (and focussing now just on medical practitioners), the state medical board employed its own staff to handle the receipt and preliminary assessment of complaints. Those staff, their necessary skills and the quality and timeliness of their work were all directly under the control of the state medical board. Under the national scheme, each state board has no such responsibility and must simply accept whatever staff AHPRA provides. Medical complaints can be sensitive and complex to handle and a high degree of knowledge, experience and skill is required if the system is to work efficiently and sensitively. In my time as President of the Medical Practitioners Board of Victoria, the Board employed both legally qualified and medically qualified investigating officers. While salaries were necessarily higher, the benefits of their skill and knowledge made this a sensible use of resources.
By comparison, there is a sense that the new system seems to be back to front in the following way. Section 25 of the national law states that a key function of AHPRA is ‘to provide administrative assistance and support to the National Boards and the Boards’ committees in exercising their functions’. In practice, it appears that AHPRA, via its administrative staff, dictates to the Medical Board and its state Medical Board branches (committees) the work flows and the quality and timeliness of the work done on behalf of the Boards. To gain access to this “administrative assistance and support”, the Medical Board of Australia has to spend resources each year negotiating a “health profession agreement” with AHPRA.
Fortunately, built into the national scheme is a solution to these structural flaws, namely the New South Wales model of “co-regulation”. Under co-regulation, NSW kept its previous Medical Board, renaming it the Medical Council of NSW. The Council (working in close cooperation with the NSW Health Care Complaints Commission) handles complaints, performance and health/impairment issues, leaving registration and the maintenance of the national register in the hands of AHPRA. Although there would be some short term additional costs, it would be relatively simple for all states and territories to copy NSW and become “co-regulated”. If this were to happen, it is envisaged that the national law would remain in place and with it, the powers for the health ministers as a group to control workforce issues would also remain.
The experimental national scheme can rightfully claim that it has successfully established a single national register and with it, ready portability of registration across Australia. These key elements must be retained. As NSW has 30% of Australia’s 103,000 doctors and 27% of Australia’s 370,000 nurses, the NSW experience demonstrates that a national register can readily coexist with co-regulation.
Dr Kerry Breen is a past president of the Medical Council of Australia, a past president of the Medical Practitioners Board of Victoria and a past chair of the Australian Health Ethics Committee of the NHMRC.