Notifications

• 10,147 notifications were received, which is
  • 0.9% fewer than we received in 2019/20 (10,236)
  • 8.7% more than in 2018/19 (9,338).
• 1.6% of all registered health practitioners had notifications made about them, including the practitioners on the pandemic response sub-register. 
• 1.7% of registered health practitioners had notifications made about them, excluding the practitioners on the pandemic response sub-register. It was 1.7% in 2019/20 and 2018/19.

Our risk-assessment approach includes consideration of risk controls

The information we consider when deciding how to approach a practitioner who is the subject of a notification continues to evolve. We look at a practitioner’s overall regulatory history, practice context and setting information. For lower level conduct concerns and concerns about a practitioner’s performance, we also consider individual and organisational risk controls. 

Individual risk controls are put in place by practitioners. They can include: 

• appropriately reflecting on the cause of an issue that led to a notification and taking steps to reduce the likelihood of it occurring again
• engaging in further education that would improve the practitioner’s practice in the future
• working with a peer, mentor or supervisor to improve the way the practitioner practises.

Organisational risk controls are put in place by an employer or workplace. They can include supervision arrangements, provision of additional training, clinical governance systems and team-based care.

Health practitioner regulation literature and our own experience shows that an overwhelming proportion of health practitioners maintain safe, professional practice. 

Health practice has inherent risks, and most health practitioners constantly screen for and take steps to mitigate those risks.

When things go wrong, most practitioners respond in ways that maintain safety and professionalism.

When concerns are raised with us, it is important that we take into account the way a practitioner responded. The need for us to intervene can be reduced when we identify that the practitioner is implementing appropriate risk controls to prevent a repeat of the incident or experience.

The risk of harm to patients can also be significantly influenced by the organisation where a practitioner practises. We seek to identify organisational risk controls through our enquiries with practitioners and the places at which they practise. 

When there are strong individual and organisational risk controls in place, the need for us to take regulatory action about the performance of a health practitioner is reduced.

Engaging with notifiers

We are doing more than ever to make sure notifiers know their concerns are heard and contribute to safer practice.

When a notification is made, we aim to speak to notifiers quickly. We check we have understood the notifier’s concerns properly. We seek to understand the context in which the notifier’s concern arose. 

If we don’t think the notification is one that will need regulatory action, we try to identify other ways that the concern can be addressed.

We make records of every concern in case we receive more notifications that could indicate a pattern of behaviour that requires action by us, by an employer or by another regulator.

We provide notification outcomes in writing for all notifications. In addition, wherever it is possible, we also provide decisions and explanations over the phone.  If we have relied on individual or organisational risk controls in our decisions, we tell the notifier what those risk controls are. This helps us explain how the notification process contributes to safer professional services provided by practitioners.

Engaging with practitioners to support safe, professional practice

Our preferred method of engagement with practitioners who are the subject of a notification has changed. We made investigations into less complex performance concerns about practitioners less adversarial – by scheduling early, in-depth discussions with them.

When we are assessing whether we need to intervene in a practitioner’s practice, hearing firsthand reflections from a practitioner really helps. 

Understanding and validating the steps practitioners take to ensure their practice continues to be safe and professional has become an important role for our frontline staff. We’re working to ensure our team members have the skills and confidence to engage practitioners in reflective conversations focused on ways to ensure future practice protects the public.

Surveying notifiers and practitioners

We made significant changes to the survey questions for notifiers and practitioners to allow us to get feedback, identify issues and track improvements.

In addition to ensuring feedback was attributable to a specific matter (to identify our activities that were more often leading to poor experiences) we worked with the NSW Health Care Complaints Commission (HCCC) to benchmark experience data across our two organisations. We changed our survey questions to align with survey questions sent by the HCCC to enable us to compare results.

Benchmarking with another regulator helps to interpret results and set targets for improvement with a comparable organisation.

Confidentiality safeguards for notifiers

We continued to strengthen confidentiality safeguards for notifiers by acting on the recommendations of the independent review by the National Health Practitioner Ombudsman (NHPO) Review of confidentiality safeguards for people making notifications about health practitioners. We requested the review after the conviction of a medical practitioner for the attempted murder of a pharmacist who raised concerns about the practitioner’s prescribing practices.

The review made 10 recommendations, and we have now implemented most of them. Of the two outstanding recommendations, one is waiting on a change to the National Law, and the other involves an IT system upgrade, which is scheduled for completion by mid-2022.

Vexatious complaints

In a very small number of complaints we find the person who complained was wanting to do harm. Vexatious complaints are rare, but they can cause enormous damage.

We consulted on and published a Framework for identifying and dealing with vexatious notifications. The framework supports our identification and management of potentially vexatious complaints.

This resource was developed based on recommendations outlined in the Review of confidentiality safeguards for people making notifications about practitioners conducted by the NHPO. 

It builds on a research report published in 2018, Reducing, identifying and managing vexatious complaints: Summary report of a literature review prepared for the Australian Health Practitioner Regulation Agency. This research was the first international literature review of vexatious complaints in health practitioner regulation. The report found that the number of vexatious complaints dealt with in Australia and internationally is very small, representing less than 1.0%, but concluded that these complaints have a big effect on everyone involved.

Sharing information with employers

We engaged with major public and private health services who employ health practitioners to talk about our joint roles in protecting the public through ensuring practitioners’ delivery of safe care. 

This was the start of a broader campaign to ensure that our role as regulator in the broader patient safety network is better understood and the information-sharing provisions of the National Law are maximised. 

Updating the Regulatory guide

We updated and republished the Regulatory guide, which is a comprehensive guide on how we manage notifications about the health, performance and conduct of practitioners under Part 8 of the National Law.

• 42 notifications were made to Ahpra about students; this is down from 44 last year.
• 11.6% increase in the proportion of notifications resulting in conditions or undertakings affecting a student’s registration compared to last year.

They have mandatory reporting obligations.

Mandatory notifications made up 12.5% of notifications received.

We received 1,266 mandatory notifications; 14.4% more (159 notifications) than in 2019/20.

• 29.6% were about medical practitioners
• 47.6% were about nurses
• the number of mandatory notifications about impairment (453) is up from 322 in 2019/20
• immediate action arising from mandatory notifications was considered on 351 occasions and taken 271 times.

The often serious nature of mandatory notifications is reflected in the outcomes.

• 31.3% of completed mandatory notifications resulted in regulatory action being taken (compared to 14.2% for all notification categories).

Regulatory action taken about mandatory notifications is down from 35.8% in 2019/20.

This interim action protects the public while more information is obtained.

• Immediate action was taken 597 times, 2.9% (17) more times than in 2019/20.
• Immediate action was taken on 5.9% of notifications received.
• This is a similar proportion of immediate action taken as a percentage of notifications received in previous years (5.7% in 2019/20 and 4.1% in 2018/19).

The small number of practitioners who breach appropriate professional boundaries with patients cause immense harm.

We received 568 notifications involving a possible failure to maintain appropriate professional boundaries. These can range from comments made by a practitioner to a patient during a consultation, or even online, that are deemed inappropriate when considered against the relevant National Board's Code of conduct, to inappropriate sexual relationships or even unlawful sexual acts. This was:

• 22.4% more than we received last year (464) 
• 83.5% were made about practitioners in three professions:
  • medical practitioners (53.2%)
  • nurses (19.5%)
  • psychologists (10.7%).

Boundary notifications received were:

• 5.5% of all medical practitioner notifications
• 5.3% of all nurse notifications
• 9.3% of all psychologist notifications.

Immediate action was considered on 258 occasions and taken 161 times, with 34 matters yet to be decided at 30 June. Of the immediate action taken:

• 52.2% was about medical practitioners
• 19.9% was about nurses
• 10.6% was about psychologists.

Boundary notifications had a higher proportion of suspensions through immediate action (34.9%) compared to all notifications (27.9%). National Boards:

• imposed conditions (16.7%)
• accepted an undertaking (7.0%)
• after consideration, decided not to take immediate action (24.4%).

The serious nature is reflected in the outcomes. Action was taken more often about boundary notifications:

• 10.3% resulted in a caution or reprimand (compared to 5.0% for all notifications)
• 12.8% resulted in conditions being imposed on a practitioner’s registration (compared to 7.2% for all)
• 5.0% resulted in a practitioner’s registration being surrendered, suspended or cancelled (compared to 0.7% for all).

The higher risk profile of boundary matters is also reflected in the stage of closure:

• 53.5% closed following an investigation (compared to 24.5% for all notifications) 
• 34.5% closed at assessment (compared to 72.5% for all notifications).
• 9.2% closed after referral to a tribunal (compared to 1.2% for all notifications).

We received 10,147 notifications about 7,858 practitioners: 4,839 practitioners (61.6%) hadn’t had a notification made about them before and 3,019 (38.4%) had had a notification made about them in previous reporting years.

Of those medical practitioners who received a notification this year, 51.3% (2,172) had had a notification made about them in previous years. For dental practitioners who received a notification this year, 45.5% (251) had had a notification made about them in previous years. 

Of the 3,019 practitioners who had had a notification made about them in a previous reporting year, 71.9% (2,172) were medical practitioners, 8.5% (256) were nurses and 8.3% (251) were dental practitioners.

For 80% of the practitioners who were the subject of a regulatory action it was for the first time

The notification may have been received in a previous year and the action taken may have been about one or more notifications. 

Most regulatory action (80.5%) was taken about a practitioner who had not had regulatory action taken about them before. A regulatory action was taken about 976 practitioners for the first time, and 237 practitioners (19.5%) had been subject to a regulatory action before.

In very serious cases, multiple notifications about a practitioner can be referred to a tribunal for it to make a decision about all open notifications about the practitioner at the same time.

In 70% of cases, after our initial assessment, we had enough information to close the notification. 

Following an assessment, 70.8% of notifications were closed and did not require an investigation:

• in 73.4% of these cases the National Board decided that regulatory action was not required
• in 15.8% of these cases, it was decided that a complaint raised with a health complaints entity (HCE) would be retained by it
• in 10.7% of these cases, the National Board took regulatory action by: referring the notification to another body, cautioning the practitioner, imposing conditions on registration, or accepting an undertaking.

When a National Board decided after the initial assessment that regulatory action was not required, common reasons included:

• a reasonable standard had been met by the practitioner
• when we consider it in the context of everything we know about the practitioner and their practice, we have confidence that patients will be able to safely access services from the practitioner in the future
• when we consider the response to the concerns from the practitioner, including their reflections on what could be done better and any changes to practice they have implemented, there is no need for further action by the National Board
• when we consider the environment in which the concern arose, we have confidence that employers and other health service organisations who have important roles to play in patient safety have taken proper steps to ensure future patients are protected.

Does the Board always decide to investigate?

• No – a National Board decides to investigate practitioners only when there is a potential risk and insufficient information to make a properly informed decision.
• 27.4% of notifications progressed from assessment to investigation because the National Board required more information before it could make an informed decision (26.2% in 2019/20 and 29.6% in 2018/19).
• 3,172 notifications about 2,447 practitioners were referred for investigation.

How long does it take to close notifications?

We closed 10,121 notifications:

• 8.9% more than in 2019/20 (9,291)
• the highest number since the National Scheme started
• 14.2% resulted in regulatory action about a practitioner
• 14.7% were referred to another body; or to a health complaints entity for consideration of early resolution, conciliation or other complaint resolution outcome
• 71.1% resulted in the National Board deciding that regulatory action was not required:
  • while there is no threshold that needs to be met to make a notification, National Boards can elect to close a notification if it considers it unlikely to result in action – this happened in about 50% of these notifications
  • in 9.0% of these cases, the practitioner had taken steps to address the concerns expressed in the notification, or steps that meant that any risk to future patients was being adequately addressed
  • in 23.7% of these cases no action was required after an investigation
• 37.0% of all notifications were closed in less than three months
• 72.0% were closed in less than six months:
  • this is a slight improvement on last year (71.6% in 2019/20) and the year before that (68.2% in 2018/19)
• the average time taken to close matters in assessment increased to 105 days, from 100 days
• 21.1% of notifications were open for longer than 12 months, up from 15.4%
• 1.7% increase in the average time taken to complete notifications, from 177 to 180 days
• 19.6% increase in the average age of open notifications, from 209 to 250 days.

We received 1,948 responses to our post-notifications surveys, 59.3% were from practitioners.

Practitioners tend to think we are on the side of the patient.

It’s not uncommon for practitioners to feel judged when we tell them someone has made a notification. We’re making changes to the language we use to explain notifications based on surveys of practitioners who have been through a notification process.

One practitioner told us that seeing a patient’s allegation repeated in our initial letter made them feel that we accepted what the patient had told us as fact. 

‘[Complainants] can say untruthful things with personal bias and insult me professionally. I would have liked to challenge that person and ask them to justify their comments.’

We attempt to contact every practitioner who is the subject of a notification by phone. That way we have the opportunity to explain what a notification is – and what it isn’t. 

Practitioners are responding to this change positively. Practitioner satisfaction with the notification process overall increased to 59% in comparison to 53% last year. 

‘The matter was resolved quickly and not in a punitive way. I think Ahpra handled the whole matter in a kind and expeditious manner. It was nothing like I imagined it to be

Notifiers tend to think we side with the practitioner.

Many notifications end without us taking regulatory action about the practitioner. Notifiers felt that this was because we represented practitioners and protected them from the complaint.

‘I am disappointed that there was no consequence nor penalty for [the practitioner] whatsoever.’

Our risk assessment and controls approach helps us share information with notifiers about actions that a practitioner or their employer has taken to prevent a similar incident arising again. 

Notifiers are letting us know, in our post-notification outcome surveys, that knowing about these actions can make a difference.

‘The notification officer took details by phone. I got regular communications by email about progress and felt officers made adjustments to help me understand, which was appreciated. It was helpful to know that [the practitioner] made sure no one else would go through what I did.’

'Knowing that the practitioner as well as their employer was taking what I reported seriously showed the system was working.'

Practitioners are acknowledging the benefits of this approach as well!

‘The outcome was fair and reasonable and Ahpra recognised the large effort I put into my response and into my self-improvement.’

It can be confronting and feel overwhelming to be the subject of a notification.

Practitioners often tell us that they thought notifications were only about very serious concerns.

‘When I received the notification, even though I was told there was no case against me, I felt very anxious until I could contact someone the next day. I had never received even an informal complaint against me in 30 years. I was worried what the complainant’s issue was that was so bad it went to Ahpra.’

Practitioners tell us that hearing from us directly helps. They also have helpful advice about seeking support from peers, professional associations and indemnity providers early.

‘The lady who conducted the initial contact explained how it would work and she helped ease my shock and anxiety.’

‘It is a fair process and just hang in there. It gives [practitioners] an opportunity to reflect on their practices and improve … take it as constructive criticism though it is very stressful to wait for the outcome.’

‘The process can take an extremely long period. Seek the assistance of your PI provider early.’

Sometimes we refer serious matters to the police.

It’s important to understand that we are a regulator of professional standards. When a practitioner’s conduct has the potential to amount to criminal conduct, having the police investigate and then charge and prosecute is important. It is the role of the criminal justice process to investigate and, where relevant, punish individuals for criminal behaviour. 

We explain the role of regulation to notifiers. 

Sometimes notifiers expect that a practitioner will suffer a punishment when something has gone wrong.

‘Nothing was resolved … I see no transparency or accountability in this case. [The practitioner] is still able to practise and wasn’t punished in any way for what they did wrong.’

It’s important to know what our role is, and what it isn’t. We’re here to make sure that risk to future patients is minimised. We use concerns notifiers tell us about as a trigger to check whether things need to be done to ensure that.

‘The eventual outcome was everything that I had hoped for – education, not punishment (though initially I was very angry with the person under investigation).’

Practitioners can be relieved when they hear that we won’t take any further action but they can find the process very stressful.

‘I found my experience stressful and bewildering. I had been contacted by phone initially and informed about the notification. I heard nothing more for months until [I] received a notification stating no further action.’

‘Ahpra was objective in their review and tried to balance the issues raised. Although I may not have agreed with the whole of the outcome, Ahpra was reasonable and endeavoured to be fair as much as possible to all parties concerned.’