Chapter 3 Accreditation, registration and other processes

3.1                   To practice medicine in Australia IMGs need to have their medical qualifications accredited and their medical knowledge and skills assessed. These processes are designed to assess eligibility for IMGs to work towards full registration, allowing them to practise in Australia either as a general practitioner or specialist. The Australian Medical Council (AMC) and the Medical Board of Australia (MBA) through the Australian Health Practitioners Registration Authority (AHPRA) are primarily responsible for accreditation and registration.

3.2                   In addition to navigating the AMC and MBA/AHPRA processes, IMGs seeking to practise in Australia also usually need to interact with a range of other government and non-government organisations to formalise their residency and employment arrangements.

3.3                   This Chapter provides a detailed description of the accreditation and registration processes that are available to IMGs and briefly outlines other inter-related processes that an IMG may have to pursue to practise in Australia and progress toward full medical registration.

Overview

3.4                   When an IMG seeks to work as a medical practitioner in Australia they have to engage with a number of organisations, including, but not limited to:

n  the Australian Medical Council (AMC) for recognition of academic qualifications and the certification of documents;

n  a specialist medical college for assessment of equivalence of qualifications and experience if seeking Specialist Registration;

n  the Medical Board of Australia (MBA) through the Australian Health Practitioner Regulation Agency (AHPRA) to gain registration as a medical practitioner;

n  the Australian Government Department of Immigration and Citizenship (DIAC) to arrange permanent or temporary migration to Australia;

n  the Australian Government Department of Health and Ageing (DoHA) for information on Districts of Workforce Shortage (DWS) if they are seeking to work in a DWS;

n  Medicare Australia to acquire a Medicare Provider Number;

n  state governments for advice on Area of Need (AoN) if seeking an AoN position;

n  employment and recruitment agencies; and

n  employers (depending on visa class and the type of registration).

3.5                   The sequence in which an IMG needs to engage with each of these organisations depends on a range of individual circumstances. Typically, an IMG commences the process of attaining full Australian medical registration with the following initial steps:

n  sourcing all of the documentation required for immigration, accreditation and registration purposes;

n  if not in English, ensuring that all relevant documentation has been translated by a certified interpreter;

n  having all the necessary documents verified in accordance with the requirements of the relevant organisation or agency;

n  passing prescribed English language proficiency exams;

n  completing a number of forms relevant to their selected immigration, accreditation and registration pathway in the exact prescribed format; and

n  paying the relevant application fees.[1]

3.6                   Failure to complete any of these steps adequately can result in an increase in costs associated with the program, as well as increasing the total amount of time expended applying to work in Australia and gaining registration.

3.7                   This Chapter outlines the accreditation and registration processes that an IMG must follow when seeking employment in Australia. This Chapter does not provide an analysis of the issues arising from these processes. Consideration of issues presented in submissions and raised by witnesses in relation these processes can be found in later Chapters of the report.

Accreditation

3.8                   Under the National Registration and Accreditation Scheme (NRAS) the AMC is the national authority responsible for the accreditation of medical professionals. It is also responsible for the accreditation of university medical schools and the specialist colleges that deliver medical training.^[2]

3.9                   The functions of the AMC are to:

n  develop accreditation standards, policies and procedures for medical programs of study based predominantly in Australia and New Zealand and for assessment of international medical graduates for registration in Australia.

n  assess, using the approved accreditation standards, undergraduate medical programs (the specialist medical colleges assess postgraduate programs) and the institutions that provide them – both those leading to General Registration and those leading to Specialist Registration of the graduates to practise medicine in Australia.

n  assess other countries’ examining and accrediting authorities to decide whether persons who successfully complete the examinations or programs of study conducted or accredited by those authorities have the knowledge, clinical skills and professional attributes necessary to practise medicine in Australia.

n  assess the knowledge, clinical skills and professional attributes of overseas qualified medical practitioners seeking registration to practise medicine in Australia.^[3]

3.10               Depending on individual circumstances and the type of registration sought, there are a number of pathways which IMGs can follow. Regardless of the pathway selected however, the AMC requires all IMGs to undergo the process of primary source verification of qualifications and provide proof of identity.

Primary source verification of qualifications and proof of identity

3.11               The Medical Board of Australia (MBA) has established a national policy for all IMGs for the assessment of qualifications by the International Credentials Service of the Educational Commission for Foreign Medical Graduates (ECFMG) of the United States. The AMC administers the process for primary source verification (also known as EICS) which involves:

... the medical qualifications documents of all IMGs being electronically scanned and sent to the Educational Commission for Foreign Medical Graduates of the United States (ECFMG) for verification. The ECFMG forwards the documents on to the original issuing authorities for confirmation that they were issued to the IMG concerned. The ECFMG maintain an annually updated list of designated officials who are authorised to verify qualifications.[4]

3.12               In addition to primary source verification, IMGs are also required to fulfil proof of identity requirements to verify that they are in fact the person they claim to be. This requires an applicant to supply a certified copy of his/her passport, plus one other certified copy of identification from a list provided, which includes drivers licence, credit card or current registration.[5] At least one of the submitted documents must include both a recent photograph and the applicant’s signature.

3.13               As noted below, the AMC’s proof of identity process which is an integral part of the accreditation process, is separate and distinct from the MBA/AHPRA proof of identity process which is needed for registration:

All applicants for medical registration will be required to satisfy the Proof of Identity Framework and Requirements of the Medical Board of Australia, which is separate to the AMC's requirements, in order to obtain medical registration.

Please note that some of the identification requirements set out by the Medical Board of Australia cannot be met by applicants applying from overseas. The AMC has therefore developed its own proof of identity requirements that can be met by doctors applying from overseas for assessment through the AMC.[6]

AMC pathways to registration

3.14               All IMGs need to commence the process of registration by applying to the AMC to have their medical training accredited. There are a number of pathways available including the following:

n  Competent Authority Pathway

->    Advanced Standing; and

->    Workplace performance assessment (minimum of 12 months).

n  Standard Pathway

->    AMC Examination; and

->    Workplace-based Assessment.

n  Specialist Pathway

->    Specialist IMGs seeking registration for independent practice; and

->    Area of Need (AON) Specialist Pathway.^[7]

3.15               It is at the IMG’s discretion which pathway they apply for. The outcome of the AMC process is the provision of the AMC certificate which enables an IMG to apply for either Provisional or Limited Registration[8] depending of the pathway chosen, and to commence work in the Australian medical system.[9]

3.16               It is also important to note that once an IMG’s medical training has been accredited by the AMC, they must also satisfy all of the MBA’s registration requirements in order to be eligible for registration. The registration requirements are outlined later in this Chapter.

The Competent Authority Pathway

3.17               The Competent Authority Pathway is for non-specialist IMGs who have obtained their medical qualifications in a country that is considered to have a comparable medical education system to Australia and is listed by the AMC as an approved competent authority. At present, competent authorities that are recognised are:

n  United Kingdom (General Medical Council);

n  Canada (Medical Council of Canada);

n  United States (United States Education Commission for Foreign Graduates, the Accreditation Council of Graduate Medical Education);

n  New Zealand (Medical Council of New Zealand); and

n  Republic of Ireland (Medical Council of Ireland).[10]

3.18               In addition to the five countries listed above, the AMC has indicated that is actively considering extending competent authority status to other countries with substantially comparable systems of medical education and training. Extending the list of competent authorities is considered by the Committee in more detail in Chapter 4.

3.19               In being assessed through the Competent Authority Pathway an IMG is eligible for ‘advanced standing’ towards the AMC Certificate. An IMG with ‘advanced standing’ may apply for Provisional or Limited Registration through the MBA/AHPRA. The IMG is generally then required to undertake a minimum of twelve months workplace performance assessment in a designated position prior to being eligible to receive the AMC Certificate.^[11]

3.20               Upon successful completion of this pathway the IMG is awarded an AMC Certificate and is eligible to apply for General Registration through the MBA/AHPRA.^[12]

The Standard Pathway (2-part assessment)

3.21               IMGs that completed their medical training at institutions not presently on the AMC Competent Authority List are required to undertake screening and examination of their medical knowledge and skills. IMGs who are not seeking Specialist Registration may be eligible to gain registration through the Standard Pathway.[13]

3.22               To gain the AMC Certificate through the Standard Pathway an IMG must successfully complete the following sequential components:

n  the AMC Multiple Choice Question (MCQ) Examination; and

n  the AMC Structured Clinical Examination (SCE).^[14]

3.23               The AMC Examinations are designed to assess the medical knowledge and clinical skills of IMGs whose basic medical qualifications are not recognised by the MBA; that is, doctors trained in medical schools that have not been formally reviewed and accredited by the AMC.

3.24               The AMC MCQ Examination was a computer-administered multiple choice question examination that was used at the commencement of the inquiry. It contained 300 items (240 of which were scored) and was available on secure computer sites both in Australia and offshore.[15]

3.25               In 2011 the AMC MCQ Examination was replaced by the AMC Computer Adaptive Testing Multiple Choice Question (AMC CAT MCQ) Examination, a computer-administered fully integrated examination delivered in one (3 ½ hour) session that consists of:

n  150 multiple choice questions (where there is one correct response from five options); and

n  120 scored multiple choice questions and 30 pilot (non-scored) multiple choice questions.[16]

3.26               The AMC CAT MCQ Examinations are conducted in examination centres in Australia and worldwide.

3.27               The SCE[17] assesses clinical skills and is conducted in teaching hospitals in Australia. The SCE is a multi-station 16 component test including three obstetrics/gynaecology stations and three paediatrics stations.[18]

3.28               Once these examinations have been passed the IMG is issued with an AMC Certificate and is eligible to apply to the MBA/AHPRA for Provisional or Limited Registration. To achieve General Registration, the IMG is usually also required to complete 52 weeks of supervised practice. During these 52 weeks IMGs are generally expected undertake the following hospital based components:

n  10 weeks of surgery;

n  10 weeks of medicine; and

n  8 weeks of Emergency Medicine.^[19]

3.29               Applicants for General Registration who have not completed any part of the core rotations in Australia must be able to demonstrate to MBA/AHPRA that they have achieved the learning outcomes expected in the rotation/s they have not undertaken.[20]

The Standard Pathway (Workplace-based Assessment)

3.30               The Standard Pathway (Workplace-based Assessment) has been established as an alternative pathway to the AMC Clinical Examination and tests clinical skills in the actual environment of doctors' everyday practice.

3.31               According to AMC guidelines, an IMG must pass the AMC CAT MCQ to be eligible for the Standard Pathway Workplace-based Assessment, and must:

n  provide evidence of English Language Proficiency;

n  provide evidence of Primary Source Verification (this does not need to be completed prior to commencing the pathway, but is needed to obtain the AMC Certificate); and

n  have obtained Limited Registration through MBA/AHPRA; and

n  be currently employed in a clinical position with an AMC-accredited authority.[21]

3.32               The AMC advised the Committee that although this pathway was included in the original 2007 COAG IMG Assessment Initiative proposals, it was not endorsed and signed off by all Australian jurisdictions at that time. As a result, implementation of this pathway has been delayed. Presently this pathway is not available nationwide and is currently being trialled in four state (NSW, Vic, Tas and WA).[22] IMGs that successfully complete this pathway are entitled to apply for General Registration.[23]

3.33               The Committee comments further on the value of the workplace-based assessment pathway and its availability in Chapter 4 of the report.

Specialist assessment

3.34               IMGs who are deemed to be specialists or who have trained as a specialist in their country of origin may pursue one of the pathways towards registration as a specialist medical practitioner in Australia.[24]

3.35               Assessment of an IMG’s claims for Specialist Registration is conducted by one of Australia’s sixteen specialist medical colleges. Once an IMG’s qualifications are verified through primary source verification, the AMC refers the IMG to the relevant specialist medical college to receive specialist assessment of their qualifications. The AMC is responsible for the accreditation of specialist medical colleges.

3.36               There are two pathways an IMG may follow to achieve specialist accreditation:

n  Specialist Pathway (Full recognition); and

n  Specialist Pathway (Area of Need).

The Specialist Pathway (Full Recognition)

3.37               This section provides an overview of what ‘generally’ occurs when a specialist IMG uses the Specialist Pathway to seek Specialist Registration in Australia. However, it should be noted that each specialist medical college has its own assessment process.

3.38               The AMC noted the challenges faced in reviewing overseas specialist training, noting that it presented:

... an even more complex challenge for recognition and registration than basic or primary medical training. There are substantial differences in the format and content of specialist training and practice between countries. Some adopt a formal postgraduate training program administered on completion of a primary (or undergraduate) medical course. Other countries integrate specialisation into the primary (or undergraduate) training with a shorter period of postgraduate specialist training than would be considered generally appropriate in Australia or other countries with developed specialist training schemes. In other countries again, there may be no formal postgraduate specialist training as such, but relevant work experience may lead to licensure to provide ‘specialist’ medical services.[25]

3.39               As with the Competent Authority Pathway and the Standard Pathways, the AMC has a significant role in administering the process. Essentially, specialist medical colleges assess IMGs by comparing each applicant to an Australian-trained specialist. In assessing the applicants, specialist medical colleges make an initial assessment that the applicant is either:

n  substantially comparable with an Australian-trained practitioner, in which case the applicant is considered suitable for recognition as a specialist. The applicant is eligible to apply for admission to Fellowship of the relevant specialist medical college, subject to up to 12 months work under oversight to confirm the initial assessment, and to ensure the practitioner's satisfactory integration into the Australian health system (this is sometimes termed ‘peer review’); or

n  partially comparable with an Australian-trained practitioner, where the applicant requires up to two years further up-skilling in aspects of the discipline to reach the standard of an Australian-trained practitioner; or

n  not comparable with an Australian-trained practitioner, in which case it is necessary for the applicant to enter the relevant specialist college training program on a competitive basis with Australian-trained graduates, possibly with some recognition of previous specialist training undertaken overseas or pursue another pathway.^[26]

3.40               Table 1.1 presents the 11 step Specialist Pathway to registration as a specialist medical. It details actions undertaken by the AMC, the applicant, the MBA and the relevant specialist college.

Table 3.1        Eleven step specialist pathway to registration as a specialist medical

Step	Process
1	The AMC receives forms and documentation from applicant
2	The application is assessed through AMC Primary Source Verification
3	Referral is sent to the relevant college and the applicant is advised that this has happened
4	The applicant completes and sends Form SC[27] and initial assessment fee to specialist college
5	The college assesses the application against college standards to determine compatibility to an Australian-trained specialist
6	The AMC receives a report from the specialist medical college advising of applicant’s level of comparability. The report forwarded to applicant. Note: at this stage in the specialist assessment process ·         an applicant who has been determined to be substantially comparable to an Australian trained specialist proceed to step 9. ·         an applicant who has been determined to be partially comparable to an Australian-trained specialist and to require additional components of the assessment procedure proceed to step 7. ·         an applicant who has been determined to be not comparable to an Australian-trained specialist has their application for specialist assessment discontinued.
7	The applicant advises the AMC in writing of their intentions to comply with the requirements set out in the specialist medical college’s initial assessment (termed Report 1)[28]
8	The AMC then advises the specialist medical college of the applicant’s intention to comply with the requirements set out in Report 1, for example undergo 24 months of peer review.
9	Following the applicant’s completion of Report 1 requirements the Specialist Medical College advise the AMC of final assessment decision via the second assessment by the specialist medical college (termed Report 2)[29]
10	The AMC receives Report 2 from the college and forwards a copy to the applicant.
	Note: at this stage in the specialist assessment process: ·         an applicant who has been determined to be substantially comparable to an Australian trained specialist proceeds to step 11 ·         an applicant who has been determined not to be comparable to an Australian trained specialist has their application for specialist assessment discontinued.
11	The AMC advise the relevant medical board of the applicant’s eligibility to present for registration as a specialist.

Source:       Australian Medical Council, Submission No 42, p 15.

The Specialist Pathway (Area of Need)

3.41               Specialist IMGs who wish to practice their specialty in a position that has been designated as an Area of Need (AoN) position are able to apply to the AMC through the Specialist AoN Pathway.

3.42               AoNs are declared by the relevant state and territory governments. Although methods of defining them vary between jurisdictions, essentially an AoN is any location in which there is a lack of specific medical practitioners, or where medical positions have remained unfilled following various recruitment efforts. AoNs may apply to specialist positions in both public and private sector.[30]

3.43               Because of the identified need, the accreditation process is fast-tracked by all parties involved in this pathway. The AMC website details the application process for those seeking to work in an AoN as follows:

The documentation requirements and arrangements for processing ‘Area of Need’ Specialist Applications are similar to those for applications through the standard Australian Medical Council (AMC) Specialist Pathway for overseas-trained specialists.

However, there are some differences because the AMC and the assessing college process area of need applications in parallel to save time.[31]

3.44               To pursue the Specialist AoN Pathway, an IMG must have already been selected by an employer and deemed suitable for an AoN specialist position. The AMC verifies documentation related to the specific job requirements and at the same time, the relevant specialist medical college assesses the applicant against the detailed position description provided by the jurisdiction, rather than the standards required of an Australian-trained specialist in that discipline.^[32] If the outcomes of the AMC and special college assessment processes are satisfactory, the specialist college advises the MBA and the employer that the IMG is suitable to fill the AoN. The assessing college also proposes any limitations it deems necessary in relation to the extent and nature of the IMG’s practice. On the basis of this information the MBA/AHPRA proceeds with an AoN Limited Registration. This registration is linked to ongoing monitoring and assessment undertaken by the college over a defined period. Reports are provided to the employer and the MBA, with continued registration being depended on satisfactory performance.

3.45               It should be noted that specialist IMGs assessed as suitable to work in a specific AoN may not be assessed as substantially comparable to an Australian-trained specialist and suitable for independent practice. This can drastically reduce the mobility of specialist IMGs employed under the AoN scheme. It is expected that IMGs working in AoN positions should be working towards qualifying for General or Specialist Registration, or planning to return to their country of origin after gaining experience in Australia.[33]

Registration

3.46               The purpose of registration of IMGs is to ensure that all doctors practising medicine in Australia meet a minimum standard equivalent to their Australian counterparts. This ensures that the Australian health system maintains its high standard of quality and safety.

3.47               The Medical Board of Australia (MBA) is responsible for the registration and regulation of medical practitioners. Once medical practitioners are registered they are able to practise medicine in Australia.

Categories of registration

3.48               The MBA can register medical practitioners including IMGs (provided they meet the registration requirements) under several categories. These categories include:

n  General Registration;

n  Provisional Registration;

n  Limited Registration; and

n  Specialist Registration.

General Registration

3.49               General Registration allows medical practitioners to practice independently in all fields of medicine.[34] Most medical practitioners in Australia practice under General Registration.[35] General registration (s 52 of the National Law) is available to medical practitioners:

n  who have completed a medical degree and an approved internship in Australia or New Zealand; or

n  who have had their eligibility assessed through the Competent Authority Pathway and have completed a period of supervised training in accordance with the MBA/AHPRA registration standard; or

n  who have qualified outside of Australia or New Zealand, and demonstrated equivalence by obtaining the AMC certificate via the AMC examination process and completed a period of supervised practice.[36]

Provisional Registration

3.50               Provisional Registration is granted to Australian or New Zealand graduates who are applying to undertake an approved intern position. Intern positions are approved by the MBA and are of usually 12 months duration. After successful completion of the intern year, practitioners working under Provisional Registration may apply for General Registration.[37]

3.51               IMGs who have obtained the AMC certificate through the AMC Standard Pathway are also eligible for Provisional Registration. As noted in the preceding section, IMGs applying for General Registration are generally expected to have undertaken a period of supervised practice.[38]

Limited Registration

3.52               Limited Registration is available to medical practitioners whose medical qualifications are from a medical school outside of Australia or New Zealand.[39] Limited Registration is available for both specialists and non-specialists. It allows a medical practitioner to practise under supervision. Practise under this form of registration may be limited in scope, duration or by location.[40]

3.53               The purpose of providing Limited Registration is to ensure that IMGs work within a framework that ensures public safety and which encourages them to reach the Australian standard.[41]

3.54               The MBA reported in its submission that Limited Registration is always granted for a specific purpose, namely:

n  to allow for work in a designated AoN position;

n  for postgraduate training or supervised practice;

n  to allow practise in the public interest; and

n  for non-practising registration for teaching or research.^[42]

Limited Registration for Area of Need

3.55               IMGs who are working under Limited Registration to work in an AoN position (s 67 of the National Law) are usually working under supervision in an area of medical workforce shortage. As noted earlier, while definitions for AoN differ between state and territory jurisdictions, IMGs practising medicine under this category must comply with the relevant MBA Registration Standards which include:

n  compliance with a supervision plan;

n  compliance with a professional development plan;

n  authorising and facilitating regular reports from their supervisors about their safety and competence to practise; and

n  continued satisfactory performance.[43]

 

 

Limited Registration for Postgraduate Training or Supervised Practice

3.56               Limited Registration for Postgraduate Training or Supervised Practice (s 66 of the National Law) is for IMGs who are undertaking supervised medical training in Australia. IMGs practising medicine under this category of registration must comply with relevant MBA Registration Standards which include:

n  compliance with a supervision plan;

n  compliance with a training plan;

n  authorising and facilitating regular reports from their supervisors about their safety and competence to practice; and

n  continued satisfactory performance.[44]

3.57               IMGs with Limited Registration wishing to practise medicine in Australia in the longer term are expected to make progress towards gaining full General or Specialist Registration.[45]

Other types of Limited Registration

3.58               While the MBA allows for Limited Registration to be granted for other purposes (eg for the public interest or for teaching and research) these are not examined as the focus of the inquiry is on IMGs wishing to practise and qualify for full Australian registration (either General or Specialist Registration).

Specialist Registration

3.59               Specialist Registration allows independent practise in an approved area of medical specialty.[46] When registering specialist IMGs, the MBA/AHPRA takes advice from the AMC and specialist medical colleges on the qualifications and comparability of individual IMGs.

3.60               As noted in the submission from DoHA:

Specialist registration is available to medical practitioners that are assessed by AMC accredited specialist colleges as being eligible for Fellowship. AMC accredited Specialist Medical Colleges in Australia are responsible for setting and administering programs relating to specialist medical training and examinations including the assessment of IMGs. Where components of the college examination and assessment procedures are applied, they are the same as, or derived from, those that apply to local specialist trainees. The colleges provide the AMC and the MBA with advice on the outcome of assessments.[47]

Registration requirements

3.61               All medical practitioners must meet certain requirements before they are registered and permitted to provide medical services in Australia. This applies to medical practitioners trained in Australia, as well as to IMGs, who must also meet some additional requirements.[48]

3.62               In addition to fulfilling the necessary AMC accreditation requirements as outlined earlier, IMGs must also fulfil a number of MBA registration requirements. According to the MBA’s submission:

The National Law requires that applicants for registration are eligible, qualified and suitable for the particular type of registration being applied for. The requirements help the Board to ensure that an IMG applying to practise medicine in Australia:

n  is the person they are claiming to be - Proof of identity and all supporting documentation is that of the same person applying for registration;

n  is medically qualified - holds a primary medical qualification from a recognised medical school.

n  is able to communicate effectively in English to a standard expected of medical practitioners practising in Australia.

n  meets the recency of practice standard as required by the National Law which identifies whether the IMG's skills and knowledge are up-to-date with current medical practice in the area the IMG intends to practise medicine.

n  is a suitable person to practise as a medical practitioner. That is, the IMG has no previous or on-going criminal history or disciplinary action taken by another registering authority which may impact on the ability of the individual to provide competent, safe and ethical care to the public.

n  does not have a mental or physical impairment that may impact their ability to practise medicine safely.

n  will be employed in a position that is suitable for his or her level of knowledge, skills and experience and that the appropriate supervision and support mechanisms will be provided.[49]

3.63               Specific registration requirements and processes will vary depending on the registration pathway selected by the applicant, and the category of registration sought. However, there are mandatory registration requirements which apply to all applications for medical registration and to registered medical practitioners, with the exception of students and non-practicing registrants. Registration Standards which have been approved by the Australian Health Workforce Ministerial Council, define the requirements that applicants need to meet.[50]

3.64               In brief, before registering any medical practitioner the MBA must:

n  verify the applicant’s identity;

n  verify the applicant’s qualifications;

n  ensure that the applicant has undertaken an internship or period of supervised practise;

n  ensure that the applicant is a suitable person to practise medicine in Australia; and

n  confirm that the applicant complies with registration standards for:

->    English language

->    criminal history check

->    recency of practice

->    continuing professional development (CPD)

->    professional indemnity insurance (PII)

3.65               As noted earlier in this report, AHPRA was established under the National Law to administer these processes on behalf of the MBA. AHPRA commenced operating in July 2010.

Proof of identity

3.66               Proof of identity is required for any new application for registration. The MBA/AHPRA provides detailed information on what documentation need to be provided as proof of identity, noting that the documents provided must meet the following criteria:

n  All documents must be true certified or notarized copies of the original.

n  At least ONE document must include a recent photograph ...

n  At least ONE document must be in the applicant’s current name.

n  All documents must be officially translated in English.

n  All documents must be current /valid at the date of submission.[51]

3.67               The requirement includes special provisions for applicants seeking registration from overseas or who have recently (less than 6 weeks previously) arrived in Australia and who may have difficulty in supplying some documents.[52] As noted earlier, the MBA/AHPRA proof of identity process is separate to that required by the AMC.

Evidence of qualifications

3.68               IMGs are required to provide information of medical qualifications and evidence of having undertaken an internship (or equivalent). Documentary evidence (certified copies of original documents) must be provided in accordance with AHPRA’s guidelines. Applicants must also demonstrate that they have had primary source verification from the AMC.[53]

Registration and work history

3.69               In addition to evidence of their qualifications, IMGs also need to provide information relating to their registration history. Specifically the MBA/AHPRA requires a Certificate of Registration Status or Certificate of Good Standing from every jurisdiction where the applicant has been registered (including overseas registrations) during the last 10 years. According to the AHPRA guidelines original certificates must forwarded directly from the licensing or registration authority to the relevant state office of the MBA. Certificates submitted must be dated within three months of the application being lodged.

3.70               Applicants are also required to provide a comprehensive curriculum vitae (CV) detailing their work practice history, including information on any gaps in practice history of more than three months. MBA/AHPRA provides guidance on standard format that the CV should take.[54]

Employment information

3.71               Applicants for Limited Registration are also required to provide written confirmation of an offer of employment. The sponsoring employer is required to provide a statement including a detailed position description, information on proposed clinical supervisors and a detailed supervision and training plan for the applicant.[55]

Other registration requirements

3.72               In addition to the information above, IMGs also need to meet a number of suitability requirement standards including:

n  English language skills need to be demonstrated by all medical practitioners who have qualified overseas or received their secondary education overseas. All applicants must be able to demonstrate English language skills at IELTS academic level 7 or equivalent. Test results will generally need to be obtained less than two years prior to applying for registration. Exceptions are made for IMGs who obtained their qualifications in the following countries: Canada; New Zealand; Republic of Ireland; South Africa, United States of America; and United Kingdom.[56]

n  criminal history is checked for all new applicants for registration and applicants seeking registration renewal. Specific factors are considered to determine whether the criminal history of health practitioners is relevant to the practice of their profession.[57]

n  recency of practice standards requires that all practitioners must have undertaken a certain number of hours of practice, as specified by the MBA, within preceding years of registration. This ensures that medical practitioners have recent practice in the fields in which they intend to work during the period of registration for which they are applying.[58]

n  continuing professional development (CPD) is required for all registered medical practitioners, including all applicants for initial registration who are not new graduates. According to the CPD standards the purpose is to maintain, develop, update and enhance their knowledge, skills and performance to ensure that they deliver appropriate and safe care.[59]

n  professional indemnity insurance (PII) standard applies to all medical practitioners who seek to undertake any form of practice. It requires all medical practitioners to have PII which covers all aspects of their intended practice and for the whole period of the registration.^[60]

3.73               In assessing suitability for registration applicants are also requested to provide information on any disqualifications from practice, suspensions or cancellations of registration. Information on any physical or mental impairment which may detrimentally affect an individual’s capacity to practise is also required.

Pathway specific requirements

3.74               In addition to these general requirements, there are additional requirements for Provisional or Limited Registration depending on the pathway through which they seek to qualify for General or Specialist Registration.

3.75               For example, IMGs on the Competent Authority Pathways are required to provide the AMC’s Certificate of Advanced Standing and may also be required to satisfactorily complete a Pre-employment Structured Clinical Interview (PESCI).

3.76               IMGs on the Standard Pathway are required to have passed the AMC CAT MCQ, the SCE (or workplace-based assessment) and may also be required to satisfactorily complete a PESCI. This will qualify the applicant for Provisional or Limited Registration for postgraduate or supervised training. An additional period of approximately 12 months supervised practice is usually required before the applicant can apply for General Registration.

3.77               Applicants for Limited Registration pursuing the Specialist Pathway are required to provide confirmation of the specialist college assessment (co-ordinated by the AMC) identifying them as substantially or partially comparable. Where possible, the college should also provide recommendations about additional training needed for specialist recognition. Applicants require the specialist college to confirm that additional training has been satisfactorily completed to qualify for college Fellowship and Specialist Registration.

3.78               Applicants for Limited Registration AoN are also required to provide evidence of an area of need declaration for the geographical area and/or type of health service for which there is a need. This declaration is issued from the relevant state or territory Minister for Health or delegate for the jurisdiction in which the designated area of need position is located.[61]

3.79               IMGs working under Limited Registration for postgraduate training or supervised practice, or for those working in AoN positions, are expected to work towards General or Specialist Registration if they intend to continue to practise in Australia.

Registration renewal

3.80               The MBA is also responsible for registration renewals. Under the National Law, initial registration as a medical practitioner is granted for a period of up to 12 months and is then renewed annually.[62] The registration renewal date for medical practitioners with General or Specialist Registration is 30 September.

3.81               The registration renewal date for practitioners with Provisional or Limited Registration is determined on a case by case basis. This is generally on the anniversary of 12 months but may be at an earlier expiry date as determined by the delegate.

Registration renewal for Limited Registration

3.82               Until such time as they qualify for General or Specialist Registration, IMGs generally qualify for Limited Registration. When considering an IMG’s application for renewal of registration, the MBA considers whether the IMG is safe to continue to practise and whether they meet the requirements for registration. Specifically the MBA takes into account:

n  work reports from supervisors;

n  evidence of progress towards qualifying for General or Specialist Registration;

n  whether all other registration standards have been met (CPD, PII etc); and

n  mandatory declarations regarding impairment, criminal activity etc.[63]

3.83               The requirement for IMGs to renew Limited Registration allows the MBA to identify any potential risks to public health and safety which may result from an IMG continuing to practise. The MBA may refuse to renew Limited Registration if the practitioner’s employment ceases or is terminated; if the practitioner fails to comply with supervision requirements; or if significant deficiencies are identified in the practitioner’s practise.

3.84               Alternatively, the MBA may decide to impose additional conditions on the applicant’s Limited Registration. Additional conditions which may be imposed on the IMG include modified levels of supervision, amended training and professional development requirements, or additional requirements to undergo additional assessment or examination.

3.85               Under s 72(3) of the National Law, 12 month Limited Registration cannot be renewed more than three times. After this time the IMG needs to reapply for new Limited Registration.[64]

Other processes

3.86               As noted earlier, in addition to accreditation and registration processes, most IMGs wishing to practise in Australia are also required to interact with a series of other organisations and agencies. The following section briefly outlines some of the additional processes that IMGs may need to undertake.

Obtaining a visa

3.87               The Department of Immigration and Citizenship (DIAC) manages the entry and stay of people in Australia. According to information on the DIAC website a key objective is to promote a society which values Australian citizenship, appreciates cultural diversity, and enables migrants to participate equitably.[65]

Visa options

3.88               IMGs who wish to migrate for the purpose of employment are required to make contact with DIAC for a visa to enter Australia and for the right to seek paid employment. For many IMGs, as with other skilled workers, this will require seeking entry under the auspices of Australia’s skilled migration program. As outlined by DIAC:

The Department’s skilled migration program provides a number of temporary and permanent pathways for OTDs including;

n  General Skilled Migration (GSM) (permanent)

n  Regional Sponsored Migration Scheme (RSMS) (permanent)

n  Employer Nomination Scheme (ENS) (permanent)

n  Temporary Business (Long Stay) – Subclass 457.[66]

Permanent residency options

3.89               Permanent residency options are available for doctors who have achieved full medical registration in Australia.[67] The General Skilled Migration (GSM) pathway allows medical practitioners with full Australian registration to live permanently in Australia and work in independent practice. The Regional Sponsored Migration Scheme (RSMS) and Employer Nomination Scheme (ENS) also provide options for permanent residency for highly skilled workers on the basis of employer sponsorship.

Temporary residency options

3.90               The vast majority of IMGs are initially eligible for temporary residency only, generally through the Temporary Business (Long Stay) Visa (the 457 visa). As outlined by DIAC:

Australian organisations (businesses, communities or government agencies) can sponsor overseas doctors to work in Australia for up to 4 years.

Temporary visas are the usual pathway to permanent residence for doctors who do not yet hold full medical registration in Australia. Overseas trained doctors can commence a period of supervised practice and formal assessment in Australia to meet the requirements for full medical registration.[68]

3.91               To be eligible for a 457 visas applicants must:

n  be sponsored by an employer to fill a nominated position

n  have skills, qualifications, experience and an employment background which match those required for the position

n  demonstrated English language proficiency

n  be eligible for any relevant licences or registration required for the nominated position.[69]

3.92               Mr Kruno Kukoc, First Assistant Secretary, Migration and Visa Policy Division, DIAC, informed the Committee that in the 2010–11 financial year, Australia’s skilled migration program delivered approximately 4 000 doctors to Australia, with close to 3 000 of these doctors granted temporary skilled worker visas.[70]

3.93               As with all temporary visa categories, there are obligations associated with the 457 visa. Notably, if an IMG ceases employment, he or she is obliged to:

n  find another employer who is willing to nominate you

n  apply for another type of substantive visa

n  leave Australia within 28 days unless your visa expires before that time, in which case you must leave Australia prior to visa expiry.[71]

3.94               IMGs who are unsuccessful in obtaining full Australian registration in the required period, or who have been deregistered for whatever reason, have to leave Australia within 28 days or earlier, if their visa expires before that time.

Accessing Medicare practitioner benefits

3.95               To work as a medical practitioner in Australia, IMGs may need access to a Medicare provider number. The Medicare provider number is a unique identifier linked to the individual medical practitioner and the location from which they practise. The Medicare provider number is used by medical practitioners to:

n  raise referrals for specialist services; and

n  make requests for pathology or diagnostic imaging services.

3.96               A Medicare provider number may also be used to claim Medicare rebates for professional services rendered – that is, to treat private patients. [72]

Section 19AB of the Health Insurance Act 1973

3.97               However, under the Health Insurance Act 1973 (the Act), many IMGs are subject to restrictions which limit the circumstances under which they can apply for a Medicare provider number. For IMGs who are not permanent residents or Australian citizens, including most IMGs with Limited Registration, the following restriction applies:

Section 19AB of the Act applies to overseas trained doctors (OTDs) and foreign graduates of an accredited medical school (FGAMS) who gained their first medical registration on or after 1 January 1997. Section 19AB of the Act restricts their access to Medicare benefits and requires them to work in a 'district of workforce shortage' (DWS) for a minimum period of ten years from the date of their first medical registration.[73]

3.98               This legislative provision, often referred to as the s 19AB restriction or the 10 year moratorium, is intended to ensure equitable distribution of medical services across Australia, including services in outer-metropolitan, regional, rural and remote locations. The incentive to attract IMGs to work in districts of workforce shortage (DWS)[74] locations is to offer access to Medicare professional benefits by exempting them from the s 19AB restriction if they choose to work in a DWS.[75]

3.99               DWS are determined by DoHA and are geographical areas in Australia where the population's needs for healthcare have not been met.[76] The process for determining DWS is described by DoHA as follows:

Districts of Workforce Shortage (DWS) are areas where the general population has less access to GPs when compared to the national average. The Department uses the latest Medicare billing statistics, which account for all active Medicare billing, and Australian Bureau of Statistics (ABS) population to determine which areas are a DWS. This information is used to create a doctor to population ratio which is used as the basis for calculating DWS. If an area has a lower doctor to population ratio (i.e. less full time equivalent doctors) than the national average, the area is a DWS.[77]

3.100           DoHA provides a locator map which can be used by those intending to work in general practice to check whether a potential job is located in a DWS.[78] Information on DWS status of an area with respect to specialist positions is obtained by contacting DoHA’s Workforce Regulation Section.

3.101           To obtain a Medicare provider number an IMG working in a DWS needs to complete a standard application form and lodge it with Medicare Australia. Medicare Australia provides the information to DoHA which determines whether a s 19AB exemption is approved, and then notifies Medicare Australia accordingly. The Committee heard from Medicare Australia about the process of obtaining a Medicare provider number for IMGs practising in a DWS. Once an exemption has been approved, Medicare Australia provides the applicant with a Medicare provider number and the information they need to make claims for professional services.[79] According to Medicare Australia:

Much of that process, although it does involve the two departments, is seamless to the doctor.[80]

3.102           There are options for IMGs to reduce the period of their obligation to work in DWS under the s 19AB restriction. One option is to complete the requirements of the Five Year Overseas Trained Doctor Scheme run by DoHA. Eligible locations are usually those where recruitment and retention of medical practitioners has been particularly problematic.

3.103           The scheme requires IMGs to complete a period of service within an eligible rural or remote area of between three and five years. It also requires IMGs to obtain permanent Australian residency and Fellowship with either the Royal Australian College of General Practitioners or the Australian College of Rural and Remote Medicine.[81]

3.104           Alternatively, reductions on the period of the 10 year moratorium can be obtained through a ‘scaling mechanism’ available to IMGs who establish private practice in eligible regional, rural and remote areas as defined under the Australian Standard Geographical Classification – Remoteness Areas (ASGC-RA). In addition to working in an eligible location, the practice must meet a Medicare billing threshold of $5 000 per month. Table 1.2 shows the moratorium reductions available under this arrangement.

Table 1.2        Scaling of period of 19AB restriction according to location

ASGC-RA Classification	ASGC RA 1 Major Cities	ASGC-RA 2 Inner Regional	ASGC-RA 3 Outer Regional	ASGC-RA 4 Remote	ASGC-RA 5 Very Remote
Period of restriction	10 years	9 years	7 years	6 years	5 years

Source:       Department of Health and Ageing, Submission No 84.1, p 6.

Section 19AA of the Health Insurance Act 1973

3.105           Australian medical graduates and IMGs who are permanent residents or Australian citizens and who do not hold continued recognition by the Royal Australian College of General Practitioners, or the Australian College of Rural and Remote Medicine, or by a recognised specialist college, are subject to restrictions s 19AA of the Health Insurance Act 1973 (the Act). According to information on DoHA’s website:

Section 19AA of the Health Insurance Act 1973 (the Act) was introduced to recognise and support general practice as a vocational specialty, as well as to provide a framework for achieving long term improvements in the quality of doctors working in Australia.[82]

3.106           All medical practitioners restricted by s 19AA are unable to access Medicare benefits unless they participate on an approved training or workforce program under s 3GA of the Act. Programs approved under s 3GA are:

n  Rural Locum Relief Program;

n  Queensland Country Relieving Program;

n  Approved Medical Deputising Service Program;

n  Prevocational General Practice Placements Program;

n  Australian General Practice Training Program;

n  Approved Private Emergency Department Program;

n  Special Approved Placements Program;

n  Temporary Resident Other Medical Practitioners Program; and

n  Specialist Medical Colleges in Australia.[83]

3.107           Alternatively, the doctor can be placed in a workforce program where workforce shortages have occurred.

3.108           IMGs that have completed their commitment to s 19AB are subject to the restrictions under s 19AA of the Act. This means that if a doctor completes their 10 year moratorium but has not gained Fellowship or specialist recognition, they will still be subject to the restrictions.[84]

Finding employment

3.109           Once again, although the specifics will vary depending on the individual circumstances of IMGs (eg visa type, selected registration pathway etc), finding a suitable employment opportunity is often a prerequisite to initiating accreditation and registration processes.

3.110           There are many sources of information on employment opportunities that IMGs seeking to practise in Australia might access. These include:

n  newspapers and some Australian medical journals (many of which are available online);

n  some specialist medical college websites;

n  state and territory government websites which list medical vacancies in public health sector organisations, including hospitals;

n  medical recruitment agencies representing public and private employers, which actively seek appropriately qualified medical practitioners, including IMGs, to fill vacancies all around Australia; and

n  state and territory based Rural Workforce Agencies (RWA) which focus on recruitment and retention of general practitioners in rural and remote areas of Australia.[85]

3.111           Although the process of locating potential employment opportunities may be relatively straight forward, for many IMGs ascertaining the suitability of a specific position not only requires a good understanding of the myriad of processes outlined above, but also a holistic understanding of how these processes can interact and impact on one another.

3.112           For example, in addition to considering the professional merits of a specific medical position, an IMG may also need to consider whether the position has an AoN classification if he or she intends to pursue an AoN registration pathway, and whether it is located in a DWS if seeking access to a Medicare provider number. In turn, the scope of employment opportunities will be influenced the applicant’s visa type, residency status and selected registration pathway. Personal considerations such as access to social networks, to services and other supports for IMGs and their family members are also important factors.

3.113           As outlined at the beginning of this Chapter, IMGs wanting to practise in Australia are faced with a complex array of processes. While some IMGs may seek assistance with navigating these processes, others may attempt to ‘go it alone’. The remaining Chapters of this report examine issues that have been raised in evidence, based on the experiences of IMGs who have attempted to navigate the various processes, as well as other stakeholders involved with accreditation and registration of medical practitioners, or involved in medical workforce recruitment.