Chapter 6
Conclusions and recommendations
From the GP perspective we are currently undergoing the worst
crisis in our workforce in living memory and we have very limited capacity to
respond to that. Our concerns about AHPRA's performance have been around the
administrative competency. Inaccurate mail addresses for many doctors have led
to significant distress and reduced patient access. There is no phone access
that is timely to try to sort out problems. Many of our members waited for an
hour to try to get through to have questions answered; consequently, their
patients and families waited for that time as well. The internet access was of
very little help to our doctors in trying to sort through the many problems of
the registration and the culture of AHPRA was that it was the doctor's problem
and just something they had to put up with.[1]
6.1
The committee acknowledges that the implementation of the new
registration and accreditation regime for some 500,000 health practitioners was
a huge undertaking. The committee also recognises that for a new organisation
to take over the registration process from some 80 state and territory boards,
and for that organisation to be up and fully operational on the day after those
boards ceased, presented a challenge. It was a unique regulatory event, both in
Australia and overseas.
6.2
However, the implementation was far from well managed. The Australian
Medical Association described it as a 'debacle'. Ramsay Health Care Australia
did not classify the difficulties being experienced as 'teething problems',
rather it expected problems to last for the next two years.[2]
6.3
It is apparent from the evidence received that there were many
stakeholders raising concerns about the implementation of the scheme from its
earliest stages. These stakeholders had experience with registration within
their own professions. The 1992 mutual recognition scheme also provided
pointers to the possible problems that may have arisen and should have informed
the setting of the timeframes and the staging of the process. The committee
considers that the timeframes were inappropriate for such a complex task.
Further, consideration should have been given to staging the time that the
registration process for each of the ten professions was absorbed by the
Australian Health Practitioner Regulation Agency (AHPRA). In addition, the
timing of the changes to the accreditation process could have been managed so
that a more gradual transition was facilitated. A more careful management of
the implementation process may have assisted to more accurately estimate the
funds required by AHPRA to carry out its functions.
6.4
As Ramsay Health Care Australia stated, it was 'too much, too soon, too
quick'.
6.5
In addition, the sheer size of the databases to be migrated should have underscored
the potential for problems to arise during the data migration. AHPRA itself
recognised the extent of the data problems. While AHPRA maintained that delays
in passing legislation in some jurisdictions exacerbated the data migration
problems, the committee considers AHPRA's risk management was clearly
inadequate and it should have developed more appropriate plans to overcome
these problems. In particular, the committee considers that more rigorous
forward planning would have facilitated data cleansing before the transfer of
the data, as well as testing of the systems to allow a smoother migration of
the data, and as a result may have reduced the amount of incorrect information
and communication distributed by AHPRA.
6.6
Problems with accessing AHPRA staff through the 1300 call number and the
website were unacceptable. The provision of insufficient, incorrect,
inconsistent and, in some cases, no advice at all because of inadequate
training of staff constitutes a grave failure. The publication of registers
with incorrect information was an outcome of AHPRA's flawed processes. The
committee considers that these matters undermined AHPRA's ability to fulfil
its primary functions: to maintain the national register and to protect the
public by ensuring that only practitioners who are suitably trained and
qualified to practice in a competent and ethical manner are registered.
6.7
AHPRA's failure to provide practitioners with notification that their
registration needed to be renewed, and also the inordinate amount of time taken
to process registration applications, demonstrated AHPRA's poor management of
the registration process. As a result, the registration of a number of
practitioners lapsed, and the practitioners became deregistered, a matter of
significant concern. Often due to the failure of AHPRA to provide any
notification, the practitioner was completely unaware that they were no longer
registered. In some instances, practitioners only found out that they were no
longer registered when they were contacted by Medicare. This was a significant
issue as not only were practitioners concerned about the potential effect on
their professional indemnity insurance, but also practitioners ceased to see
patients immediately, causing a disruption to patient care.
6.8
The manner in which registrations were processed by AHPRA pointed to
poor planning and a lack of understanding of basic processes to keep
registrants informed, for example, lack of confirmations and the inability to
track applications through processing stages. These circumstances indicate poor
internal processes and document management.
6.9
The committee was provided with extensive evidence on the impact of AHPRA's
flawed processes. Practitioners reported loss of income, and in some cases loss
of employment. Some practitioners argued that their reputations have been
damaged as a result of incorrect registration information or deregistration
through no fault of their own. They also reported added stress and anxiety as a
result of their registration difficulties. Concerns were raised about the
implications for legal liability when practitioners continued to practice when
they did not know that they were not registered. As noted by many
practitioners, these problems took them away from their core task: the
provision of health services to patients.
6.10
Health providers also gave evidence of the impact on their
organisations. Many reported significant time was required to access
information about potential employees and to assist current employees with
registration problems. Due to AHPRA's failure to support and advise
practitioners during the transition, the onus has fallen on health providers
and employers of health practitioners.
Recommendation 1
6.11
The committee recommends that AHPRA should issue a letter of apology to
practitioners who were deregistered because of the problems revealed by the
inquiry and, where it is established a lapse or delay in registration took
place, AHPRA should reimburse practitioners for any loss of direct Medicare
payments.
Recommendation 2
6.12
The committee recommends that AHPRA should rectify any situation where a
practitioner is left liable due to their professional indemnity insurance
lapsing, or being voided, during a period where they were deregistered by
AHPRA’s administrative failings.
6.13
The effects of AHPRA's failure to adequately perform its functions were
not limited to practitioners; patients experienced financial loss as they could
not claim Medicare rebates for services provided by deregistered practitioners.
Patients of practitioners who were deregistered had appointments cancelled or
postponed. This was of great inconvenience and concern.
6.14
The committee also notes AHPRA's poor management of the registration
process has effected recruitment of overseas practitioners. This is a
significant matter: many communities in rural areas rely on overseas
practitioners to take up positions in local practices. The committee was
provided with examples of communities losing the opportunity to employ health
practitioners because of significant delays in the registration of these
practitioners. In particular, the advice provided about, and the inconsistent
administration of, the English test for overseas practitioners was seen as a
significant concern. The committee agrees that the English language requirement
is crucial; however, it should be applied in a more consistent manner.
6.15
The committee concludes that this is an area where AHPRA must
significantly improve its performance. Further, the committee considers that
updates on the registration of overseas trained practitioners should be
considered by the Ministerial Council on a regular basis. AHPRA should also
establish Key Performance Indicators to cover registration timeframes for this
category of registration and report outcomes in its annual report.
6.16
Submitters to the inquiry pointed to the lack of accountability of
AHPRA. AHPRA reports to nine ministers–eight state and territory ministers and
the Commonwealth minister for health. However, far from improving
accountability, this appears to have resulted in fragmented responsibility and
diminution of scrutiny. The committee considers that in the establishment of
AHPRA, greater attention should have been paid to accountability issues. Further,
that if other similar cross jurisdictional bodies are established,
accountability must be clearly provided for in any establishing legislation.
Recommendation 3
6.17
The committee recommends that the Commonwealth Government seek the support
of the Australian Health Workforce Ministerial Council to undertake a regular
review of the registration of overseas trained health practitioners.
Recommendation 4
6.18
The committee recommends that AHPRA establish Key Performance Indicators
in relation to the registration of overseas trained health practitioners and provide
detailed information on this matter in its annual report.
6.19
In relation to complaints about health practitioners, the committee
identified a number of areas where improvements are required including
inconsistencies in 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.
Recommendation 5
6.20
The committee recommends that complaints processing within AHPRA be
reviewed to ensure more accurate reporting of notifications and to reduce the
impact of vexatious complaints on health practitioners.
6.21
In relation to information provided to Australian Health Workforce
Ministerial Council (AHWMC), the committee notes that AHPRA officials have met
with AHWMC to provide briefings on the implementation of the National
Registration and Accreditation Scheme (NRAS). AHPRA will now meet more
regularly with the chair of the council to provide briefings on progress.[3]
However, the committee is concerned that the only public reporting of the implementation
of the NRAS and the work of AHPRA is provided in its annual report and
occasional communiqués from AHWMC. The committee considers that better
accountability mechanisms must be established to ensure that the scheme does
operate in a 'transparent, accountable, efficient, effective and fair way'.
Recommendation 6
6.22
The committee recommends that the Commonwealth Government seek the
support of the Australian Health Workforce Ministerial Council to identify and
establish mechanisms to improve the accountability of AHPRA to the parliaments
of all jurisdictions and the Australian public.
6.23
To improve consultation with professional organisations, including
provider organisations, 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.
Recommendation 7
6.24
The committee recommends that AHPRA, as a matter of urgency, establish
consultative groups with professional organisations and health providers.
6.25
A significant concern raised in evidence was that some practitioners
were deregistered because of flawed administrative processes by AHPRA including
loss of documents, incorrect contact data and lack of notification. The
committee considers that in such circumstances that there should be a grace
period so that health practitioners are not penalised for administrative
errors.
Recommendation 8
6.26
The committee recommends that the Commonwealth Government seek the
support of the Australian Health Workforce Ministerial Council to amend the
National Law to provide AHPRA with a discretion to grant a grace period where a
health practitioner faces deregistration as a result of administrative error by
AHPRA.
6.27
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.
Recommendation 9
6.28
The committee recommends that the Commonwealth Government seek the
support of the Australian Health Workforce Ministerial Council to amend the
National Law to provide further practicing classifications for practitioners in
academic institutions and for those who practise in a limited manner.
6.29
The committee received extensive evidence concerning the mandatory
notification requirements under the National Law. The committee has noted that
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 operating in
Western Australia.
Recommendation 10
6.30
The committee recommends that the Commonwealth Government seek the
support of the Australian Health Workforce Ministerial Council to implement a
review of the mandatory notifications requirements and in particular take into
account the Western Australia model of mandatory reporting.
6.31
In conclusion, the committee notes that it is stated in National Law
that:
The guiding principles of the national registration and
accreditation scheme are as follows–
(a)
the scheme is to operate in a
transparent, accountable, efficient, effective and fair way;
(b)
fees required to be paid under the
scheme are to be reasonable having regard to the efficient and effective
operation of the scheme;
(c)
restrictions on the practice of a health
profession are to be imposed under the scheme only if it is necessary to ensure
health services are provided safely and are of an appropriate quality.[4]
6.32
The committee concludes that the mistakes, omissions and poor processes
that were clearly evident from the evidence received during the inquiry calls
into question the ability of AHPRA carry out its primary purpose. For AHPRA
itself to be responsible for a breakdown of the entire system of registration
of health practitioners in Australia is a dismal example of policy
implementation and public administration.
6.33
The committee expects that the lessons learned during this phase of
implementation of the NRAS will be applied to the next tranche of professions
to come with the scheme. This will mean that AHPRA will need to adequately
address planning, timing and resource issues. In undertaking this process,
AHPRA must keep the AHWMC fully informed of developments.
Senator
Mitch Fifield
Chair
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