Chapter 1 Conduct and context of the inquiry

Referral

1.1                   Australia has one of the best healthcare systems in the world, delivering consistently high quality of care. A qualified, trained and skilled workforce is a key component to the success of the healthcare system, including an adequate number of medical practitioners. The vital contribution that international medical graduates (IMGs)[1] make to this system is widely recognised and valued. Although Australia’s reliance on medical practitioners who have qualified and trained overseas has varied over time, it is estimated that IMGs currently represent an estimated 39% of registered medical practitioners. It also seems that Australia will continue to need IMGs to maintain its medical practitioner workforce.

1.2                   In view of this continued reliance on IMGs, the challenge is to establish a system which enables suitably qualified and experienced medical practitioners to work in Australia, while also protecting the health and wellbeing of the Australian public. With the latter in mind, it is important that IMGs undergo a thorough screening process to ensure that they meet the professional standards needed to practise medicine in Australia.

1.3                   The Inquiry into Registration Processes and Support for Overseas Trained Doctors (the Inquiry) was referred to the House of Representatives Standing Committee on Health and Ageing (the Committee) on 23 November 2010. The impetus for the referral was a private Member’s motion proposed by The Hon Bruce Scott MP. By way of background on 28 September 2010, Mr Scott gave notice of the following private Member’s motion:

MR SCOTT: To move—That this House calls for:

(1) an inquiry into the role of Australia’s medical and surgical colleges in the registration process of medical graduates and overseas trained doctors; and

(2) the Minister for Immigration and Citizenship to delay the revocation of 457 visas for those doctors who have been deregistered due to failure of the Pre Employment Structured Clinical Interview, to allow adequate time for a review of their case and reassessment of their competency.[2]

1.4                   On 18 October 2010, Mr Scott’s motion was one of the items of private Member’s business which was debated in the Main Committee. In addition to Mr Scott, the following Members contributed to the debate: Mr  Shayne Neumann MP; Mr Geoff Lyons MP; Mr Warren Entsch MP; Mr Bob Katter MP; Ms Jill Hall MP; Dr Andrew Laming MP; Mr Tony Zappia MP; Mr Luke Simpkins MP; and Mr Steve Georganas MP.

1.5                   On 16 November 2010, the House of Representatives Selection Committee identified Mr Scott’s private Member’s motion as an item of business to be voted in the House on 25 November 2010. However, on 23 November 2010 the Minister for Health and Ageing, The Hon Nicola Roxon MP, referred the inquiry into registration processes and support for overseas trained doctors with the following terms of reference:

Recognising the vital role of colleges in setting and maintaining high standards for the registration of overseas trained doctors (OTDs), the Committee will:

n  explore current administrative processes and accountability measures to determine if there are ways OTDs could better understand colleges' assessment processes, appeal mechanisms could be clarified, and the community better understand and accept registration decisions;

n  report on the support programs available through the Commonwealth and State and Territory governments, professional organisations and colleges to assist OTDs to meet registration requirements, and provide suggestions for the enhancement and integration of these programs; and

n  suggest ways to remove impediments and promote pathways for OTDs to achieve full Australian qualification, particularly in regional areas, without lowering the necessary standards required by colleges and regulatory bodies.

1.6                   On 25 November 2010, the anticipated vote on the motion did not proceed. Instead the Leader of the House, The Hon Anthony Albanese MP, made the following statement in the House:

MR ALBANESE: For the benefit of the House, I also table a letter from the federal member for Maranoa, along the lines of the following:

Dear Minister— addressed to me as Leader of the House—

Regarding the planned vote tomorrow on my Private Member’s Motion of 18 October 2010, I believe that the substance of the Motion has been addressed by the Health Minister’s request for the House Standing Committee on Health and Ageing to conduct an inquiry into Registration Processes and Support for Overseas Trained Doctors. As such I do not believe a vote in the House is necessary.

I table the letter from Mr Scott, the member for Maranoa, for the information of the House as to why that vote is not proceeding today.[3]

Conduct of the inquiry

1.7                   Immediately after referral on 23 November 2010, details of the inquiry were made available on the Parliament of Australia website, and on 1 December 2010 an advertisement was placed in The Australian calling for written submissions. The inquiry was also advertised through an extensive mail out to interested parties, including peak bodies and organisations, health services and hospitals and the relevant government departments inviting submissions.

1.8                   Over the course of the inquiry the Committee received 184 submissions from organisations, government authorities and from individuals. A list of submissions is at Appendix A. A range of publications, documents and supplementary material tendered during the inquiry was received as exhibits. A list of exhibits is at Appendix B. In addition a significant volume of supplementary evidentiary material was also submitted to the inquiry. A number of submissions from individuals, particularly IMGs who have sought accreditation and registration in Australia, were accompanied by range of supporting documentation (eg certificates relating to qualifications, work history and professional training/experience, CVs, application forms and correspondence to/from accreditation/registration authorities etc). This material was received as additional documentary evidence. Information on this material is at Appendix C.

1.9                   In addition, the Committee undertook an extensive program of public hearings. Twenty two public hearings, including 12 interstate public hearings were held between February 2011 and January 2012. The Committee took verbal evidence from a range of stakeholders including: representatives of the key organisations responsible for various aspects of the assessment, accreditation and registration of medical practitioners; peak bodies representing medical practitioners; representatives of public and private healthcare facilities seeking to meet their workforce needs; representatives of medical recruitment agencies; representatives of government departments involved; and from individual medical practitioners and IMGs. Details of the public hearings including a list of witnesses, is at Appendix D.

Scope of the inquiry

1.10               The scope of the inquiry is largely defined by the terms of reference. Although the terms of reference might be read to indicate a particular focus on the role of specialist medical colleges in the assessment, accreditation and registration of IMGs, a comprehensive review of these issues necessarily requires consideration of the accreditation and registration system more broadly. Whilst not explicit in the terms of reference, any inquiry into accreditation and registration needs to consider linkages with other processes, including those associated with immigration, and initiatives to encourage medical practitioners to work in regional, rural and remote locations.

1.11               National accreditation and registration processes apply to health practitioners intending to practise in various disciplines.[4] However, in accordance with the terms of reference the Committee’s considerations are confined to issues faced by internationally educated and trained medical practitioners.

1.12               In this context, a significant number of submissions were received from individuals outlining personal experiences regarding accreditation and/or registration processes. The Committee found these submissions to be valuable, using them to form a better understanding of the issues facing IMGs seeking to practice in Australia, and of the practical implications for IMGs and their families. However, the Committee emphasises that it is unable to investigate individual cases or recommend remedies for any particular person. Rather, the aim of the inquiry is to identify systemic problems, and where possible to make recommendations for reform to address these.

1.13               As part of the inquiry process the Committee intends to review progress made in relation to the report’s recommendations at a later date.

Context of the inquiry

1.14               All medical practitioners, regardless of where they have qualified, must meet certain requirements before they are permitted to practise in Australia. As noted in the submission from the Australian Government Department of Health and Ageing:

These requirements are designed to ensure minimum standards of quality and safety, and in some cases, will result in practitioners operating under a range of conditions, including under supervision and restrictions on area and/or scope of practice.[5]

1.15               Medical practitioners, including IMGs, must demonstrate to the Medical Board of Australia (MBA) that they meet these standards before they are registered to practise. Although there is clearly a need for a robust system of accreditation and registration with sufficient checks to ensure public safety, some have argued that the regulatory frameworks to be navigated by IMGs are overly complex and their administration is flawed.[6]

1.16               Evidence to the inquiry has included various flowcharts from submitters which have sought to show how the system operates.[7] However, one witness candidly described the system as resembling ‘spaghetti’.[8] This view was shared by some other submitters, who noted that while individual stakeholders considered their own processes to be straightforward, once all of these interactions were combined, the system was far more complex and potentially confusing than it may at first appear.[9]

1.17               For IMGs seeking to practise medicine in Australia, dealing with accreditation and registration is often only part of the wider process. Many IMGs, particularly those applying from overseas, need to engage with numerous organisations to arrange for their relocation to Australia. These may include the Australian Government Department of Immigration and Citizenship (DIAC), the Australian Government Department of Health and Ageing (DoHA), state and territory governments, recruitment agencies and potential employers. Understanding and navigating multiple processes, and attempting to coordinate disparate timeframes exacerbate the challenges faced by many IMGs.

A complex system

1.18               Prior to 2010, registration of medical practitioners was the responsibility of medical boards in each state and territory and was administered separately by each. In its submission to the inquiry, DoHA informed the Committee that prior to the establishment of the National Registration and Accreditation Scheme (NRAS) that:

... registration arrangements for health practitioners, including the medical profession, were separately administered by state and territory governments. This meant that requirements for registration differed from state to state and that practitioners were required to reregister every time they wanted to practise in another state or territory. It also enabled some practitioners to move interstate in order to avoid scrutiny.^[10]

1.19               In late 2005, the Productivity Commission published a research report titled Australia’s Health Workforce.[11] The research report, commissioned by the Council of Australian Governments (COAG), reviewed a range of workforce issues, including:

n  factors affecting the future supply of, and demand for, health workers;

n  the efficiency and effectiveness with which the available workforce is deployed; and

n  what reforms to health workforce arrangements might be undertaken to improve access across the community to quality and safe health care.[12]

1.20               The report found that Australia’s health workforce arrangements were ‘extraordinarily complex and interdependent’ and identified the following as contributing factors:

n  The Australian, State and Territory Governments are involved in all of the key parts of the health workforce system, and often at several levels.

n  There are more than 20 bodies involved in accrediting health workforce education and training, and over 90 registration boards.

n  A host of professional bodies administer codes of conduct which complement formal regulation, or provide for self-regulation.[13]

1.21               In the report, the Productivity Commission proposed an integrated and coherent reform plan, making 20 recommendations to promote a more efficient, effective and responsive health workforce. Key recommendations were for there to be a single national registration board for health practitioners working in the regulated health professions[14], as well as a single national accreditation board for health professional education and training.

The National Registration and Accreditation Scheme

1.22               In July 2006, COAG agreed to establish a single national registration scheme for health professionals and a national accreditation scheme for health education and training.[15] In 2008, COAG signed the Intergovernmental Agreement for a National Registration and Accreditation Scheme for Health Professionals (the Agreement). According to the COAG Communiqué of 26 March 2008:

The new arrangement will help health professionals move around the country more easily, reduce red tape, provide greater safeguards for the public and promote a more flexible, responsive and sustainable health workforce.[16]

1.23               The Agreement set out a plan for progressive implementation during 2010, comprising the enactment of appropriate legislation by states and territories. In accordance with the Agreement, Queensland took the lead with primary legislation to implement a national scheme, enacting the Health Practitioner Regulation National Law Act 2009 (Qld) (the National Law). During 2009 and 2010, similar bills were enacted in each state and territory, providing for the implementation and operation of the National Registration and Accreditation Scheme (NRAS).^[17] The NRAS aims to:

n  improve the mobility of the health workforce;

n  stop health professionals from having to re-register every time they cross a state border to practice medicine; and

n  save time and money and to reduce inconvenience.^[18]

1.24               It is important to note that throughout this report, where there is reference to provisions of the National Law, these references have been extracted from the Queensland legislation, as it was the first state to enact the legislation implementing the NRAS. Accordingly, these provisions may not correlate directly with the corresponding provisions of each piece of legislation enacted by other states and territories.

1.25               Under the National Law, a single national medical board, the MBA, is now responsible for all matters relating to the registration of medical practitioners. Section 35 of the National Law outlines National Board functions, which include responsibility for setting the standards, codes and guidelines for the profession, including the requirements relating to specialist assessment. The Australian Health Practitioner Regulation Agency (AHPRA) was established to provide administrative support for these functions and advice on associated matters to the MBA (and national boards for the other nine regulated health professions), giving effect to the NRAS.

1.26               The National Law also allows for considerable delegation of functions,[19] enabling the MBA/AHPRA to externalise assessment and accreditation functions.[20] Specifically, s 43 of the National Law enables the appointment of the Australian Medical Council (AMC) as the independent entity responsible for the accreditation of the medical profession in Australia. The AMC is also responsible for managing the assessment and examination processes of the specialist medical colleges.

1.27               As the NRAS has now been operational for almost two years, the conclusion of the inquiry provides a timely opportunity for review.

Previous inquiries

1.28               As noted previously the complexity of the accreditation and registration processes has been a cause of concern both for Australian trained medical practitioners and for IMGs wishing to work in Australia. Not surprisingly therefore, these processes have been subject to earlier inquiries.

1.29               In 2004, the Australian Competition and Consumer Commission (ACCC), jointly with the Australian Health Workforce Officials Committee (AHWOC), conducted a review of selection, training and accreditation arrangements of all specialist medical colleges. The review included consideration of how these processes applied to IMGs. The aim of the review was to:

... explore the extent to which specialist medical colleges are operating according to the general principles of transparency, accountability, stakeholder participation and procedural fairness ...[21]

1.30               The resulting report released in 2005 made a total of 20 recommendations to improve college assessment and accreditation processes. In relation to overseas trained specialists specifically, the report recommended:

n  further consideration to the recognition of prior overseas training;

n  increased opportunities for competency-based assessment and training;

n  greater transparency of college assessment criteria for overseas trained specialists; and

n  improved access to continuing professional development for overseas trained specialists working towards specialist registration.[22]

1.31               In 2011, almost a year after the commencement of the NRAS, the Senate Finance and Public Administration Reference Committee inquired into its operation and its administration through AHPRA. While acknowledging that the implementation of the NRAS was a huge undertaking, the report noted that there were some ‘teething’ problems associated with the transition.[23]

1.32               The report noted that AHPRA’s poor administration of the registration process had effected recruitment of overseas trained health practitioners.[24] Issues frequently raised by overseas trained practitioners seeking registration through AHPRA processes related to prolonged timeframes, provision of inaccurate advice and lost documentation. Concerns were also raised in relation to English language testing and the use of specific clinical assessment tools.[25] The Senate Finance and Public Administration References Committee concluded that there was scope for significant improvement in registrations processes for overseas trained health practitioners, recommending:

n  regular review of registration processes for overseas trained practitioners; and

n  increased transparency in relation to registration timeframes for overseas trained health practitioners through the annual publication of key performance indicators to include data on this issue.[26]

1.33               In an accompanying minority report, while also acknowledging that transitional issues had led to frustration for some health professionals seeking registration, Government Senators concluded that AHPRA was already aware of many of the issues raised during the inquiry and that appropriate remedial action had been undertaken. As a result Government Senators expressed the view that the benefits of the new national registration system would become increasingly evident.[27]

Structure of the report

1.34               Following the introductory material and context presented in Chapter 1, Chapter 2 examines workforce issues. Specifically, Chapter 2 examines what is known about Australia’s medical practitioner workforce and how IMGs have contributed to meeting workforce shortages. It also considers issues associated with medical practitioner workforce planning.

1.35               Chapter 3 reviews the current system of accreditation and registration and the various pathways available to IMGs wishing to practise in Australia. It also considers departments and/or agencies that IMGs may need to interact with over and above those directly involved with accreditation and registration (eg DIAC, DoHA, state and territory government authorities, recruitment agencies etc).

1.36               Chapters 4 and 5 consider issues that have been raised in evidence with regard specifically to accreditation and registration of IMGs. The focus of Chapter 4 is on the AMC’s assessment and accreditation processes for IMGs. It also includes consideration of issues relating the role of specialist medical colleges in assessment and accreditation of specialist IMGs. Chapter 5 considers registration processes for IMGs administered by AHPRA on behalf of the MBA, and other processes which IMGs have to engage with in order to practise medicine in Australia.

1.37               Chapter 6 considers system wide issues that have been raised in evidence, primarily those associated with the transition to a national system of accreditation and registration, an apparent lack of coordination between agencies and the practical implications for IMGs of systemic inefficiencies.

1.38               Chapter 7 examines issues associated with access for IMGs and their families to support mechanisms and programs across jurisdictions. The Chapter includes consideration of access to supports for IMGs working in regional, rural and remote areas and the implications of residency status on eligibility for support.