Making it easier for internationally qualified practitioners to register

The Australian health workforce is growing but national shortages persist.

In December, National Cabinet endorsed the 28 recommendations of the final report of the Independent review of Australia’s regulatory settings relating to overseas health practitioners. The review was undertaken by Ms Robyn Kruk AO and is referred to as the Kruk review. Ahpra is the lead or has a key role in several of the Kruk review recommendations. We welcomed the findings of the review and immediately began work on reforms to make it simpler, quicker and cheaper for internationally qualified practitioners to practise in Australia.

In response to the review, Ahpra and relevant National Boards:

• removed requirements for overseas-based applicants to present in person for identity checks in Australia before their registration can be granted
• opened a new purpose-built centre in Melbourne for the examination of the clinical skills of internationally qualified nurses and midwives – this means shorter wait times for overseas-trained nurses and midwives to sit their exams so they can work in Australia sooner
• completed a review of English language standards (and health ministers approved revised standards on 14 June)
• made significant progress on a fast-track pathway to registration for specialist international medical graduates, and public consultation on a draft revised registration standard for specialist registration was carried out in June
• began scoping work on fast-track pathways for other priority professions beyond medical, as well as work to provide greater flexibility to meet other requirements such as supervision and English language skills.

What drives practitioner retention and attrition?

Understanding what motivates health practitioners to stay or leave their profession is an important aspect of workforce sustainability and quality. Analysis of registration data from 2014 to 2023 showed that the overall number of registered practitioners increased in that period, but the retention rate declined, highlighting concerns about workforce stability.

In June 2023, nine National Boards agreed to participate in the Workforce Retention and Attrition Project (WRAP). A survey was sent to 145,120 health practitioners and 18.0% completed it in full.

Most respondents said they intended to stay and provided insights into what motivates them in their work. Factors that predict whether a practitioner will stay or leave, such as work hours, years of experience, gender and age, were also examined. A paper detailing the findings has been submitted to a peer-reviewed journal and is likely to be published in late 2024, when the findings will be published on Ahpra’s website.

Expedited pathway for medical specialists

We have begun working to establish an expedited specialist pathway for specialist international medical graduates (SIMGs) in four priority areas: anaesthesia, general practice, obstetrics and gynaecology, and psychiatry.

Once it’s in place, the pathway will provide an additional route to specialist registration for SIMGs who have qualifications considered substantially equivalent or based on similar competencies to an approved medical specialist qualification in Australia.

SIMGs with a qualification that is listed as eligible for the pathway will be able to apply directly for specialist registration without requiring a specialist medical college assessment. 

We again made significant progress in implementing the Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020–2025, now in its fourth year.

Eliminating racism from Australian healthcare

In October, the ACT Civil and Administrative Tribunal delivered a landmark ruling against a doctor over discriminatory and offensive behaviour, supporting the goal of eliminating racism from Australian healthcare.

The doctor has been prohibited from providing any health service and cannot apply for registration for 12 months, after admitting that his conduct towards ophthalmologist Associate Professor Kris Rallah-Baker, a Yuggera, Warangoo and Wiradjuri man, was culturally unsafe, insulting and offensive.

This outcome is in line with changes made in 2022 to strengthen the National Law, which were supported by the Aboriginal and Torres Strait Islander Health Strategy Group.

Culturally safe notifications process

The medical and nursing and midwifery Indigenous National Special Issues Committees have been established, made up of Aboriginal and Torres Strait Islander practitioner and community members. These committees have been making decisions about regulatory matters affecting Aboriginal and Torres Strait Islander Peoples.

International regulatory excellence team award

In September at Salt Lake City, the Aboriginal and Torres Strait Islander Health Strategy Unit (HSU) and Ahpra were recognised by the peak international regulatory body Council of Licensure, Enforcement and Regulation (CLEAR) for a Regulatory Excellence Team Award for their work to ensure culturally safe practice in Australia’s health system. The award requires the team or agency to have demonstrated exceptional leadership, vision, creativity, results and outcomes above and beyond the regular functions of the job or expectations, and beyond what is normally achieved.

Increased visibility

The HSU committed to a year of visibility for their strategic work in 2023 to share progress towards eliminating racism in healthcare for Aboriginal and Torres Strait Islander Peoples. To fulfil this commitment, a number of abstracts were submitted and accepted to present at Indigenous health practitioner and regulatory conferences, in addition to having exhibition booths providing profile and engagement opportunities with stakeholder groups.

Indigenous leadership at the Combined Meeting

In October, during the week of the referendum on the Voice to Parliament, the National Scheme Combined Meeting and the first in-person Aboriginal and Torres Strait Islander Health Strategy Group was held in Naarm. The meeting featured an impressive line-up of Indigenous keynote and guest speakers. Dr Janet Smylie, Professor Lisa Whop, Dr Clinton Schultz, Dr Ali Drummond and Mr Francis Nona discussed issues topical to regulators that affect the wellbeing of Aboriginal and Torres Strait Islander Peoples.

Increased participation

Aboriginal and Torres Strait Islander workforce participation in the National Scheme and within Ahpra has continued to grow. The total number of Aboriginal or Torres Strait Islander Ahpra staff is now 23, eight more than last year. Mr Olli Wynyard Gonfond was appointed as National Director – Aboriginal and Torres Strait Islander People and Culture Programs.

Targeted recruitment campaigns resulted in the appointment of 12 new Aboriginal and Torres Strait Islander Board and committee members, bringing the current total to 44.

As a risk-based regulator, we act on concerns raised by colleagues, patients, employers and others. Where concerns relate to specific individual health practitioners, we have an established notifications process to deal with them. To gain insights into changes in the wider healthcare environment, we can analyse our data, which helps us to recognise and respond to risks early on.

However, recent trends in healthcare are moving quickly, driven by change and innovation, and there is potential for significant harm to occur that may not get reported. We saw this in the rise of cosmetic surgery in the past few years and, more recently, in newer models of healthcare marketed directly to consumers such as the surge in prescriptions for medicinal cannabis and for semaglutide for weight loss.

Maintaining a balance between access and the safety of emerging models of care that may pose significant risk is a key priority amid a growing number of prescriptions and the emergence of telehealth, online prescribing and direct-to-consumer health services.

Many of these novel risks go beyond individual health practitioners and also involve the regulation of places and products. To address them, we join forces with other regulators such as the Therapeutic Goods Administration (TGA) to take a system-wide approach to patient safety. Collaboration with other agencies is critical to keeping up with social and technological changes. Coming together to share knowledge, information and approaches results in the best outcomes for the public.

This year, we boosted our work with other regulators and services on cross-regulatory issues – leading where appropriate, supporting where needed, and taking a stewardship role in uniting organisations.

In February, we hosted a forum on medicinal cannabis that brought together health regulators to share information and regulatory intelligence, with the aim of balancing safety with access. Ahpra called this forum together to examine how the responsible regulatory agencies can work together in a rapidly growing field to ensure clarity of roles and use our regulatory tools to reduce harms to the public. 

We are part of an expert advisory group on medicinal cannabis with the TGA, and have worked with the TGA to organise discussions with state and territory pharmacy authorities about specific medications and the regulation of new models of care. We also meet with the TGA and Australian Competition and Consumer Commission about our respective work on shared issues such as vaping and artificial intelligence. 

This cooperative approach is echoed in other areas of our work. In February, we hosted a series of three symposia to explore ways to minimise distress for practitioners who receive a notification. We invited support services, mental health organisations, professional associations, co-regulators and others to collaborate on improving the experience for practitioners. 

Practitioners need support and guidance to help them understand their obligations under new healthcare models, which also call for a new approach to analysing and determining risk. Ahpra is only one part of Australia’s health system and we can’t solve these problems on our own. By leading collaborative efforts to address emerging issues, we are aiming to get ahead of them before they lead to serious harm and ensure that, among the rapid changes across the health sector, emerging models of care continue to put patients first.

Any sexual exploitation of patients is a gross abuse of trust, and Ahpra and the National Boards condemn this behaviour from health practitioners.

Action plan to improve public safety

Rates of boundary violations, which include sexual misconduct, rose again this year. In response to significant public concern and media reporting, in February 2023 Ahpra released an action plan with reforms to better protect patients. Key work this year included the following:

• Supporting National Law reforms to include practitioners’ past sexual misconduct on the Register of practitioners to help people make decisions about the practitioners they see, and to increase nationwide consistency in re-registration processes for practitioners who had their registration cancelled.
• Strengthening community voices in regulatory decision making through including more community members on committees that consider sexual boundary notifications and offering training for decision makers.
• Continuing the review of the Criminal history registration standard, to ensure the standard is contemporary and meets public expectations about who is considered safe to be registered as a health practitioner.
• Improving public information explaining the regulatory action that has been taken for a practitioner who has proven findings of professional misconduct relating to sexual boundary violations.
• Ongoing work to improve how we identify and manage sexual misconduct matters, informed by a case review and research. Findings so far are that our processes are working well, quickly identifying serious sexual boundary matters to allow immediate action. The review identified areas where we can improve how we engage with victim survivors or witnesses, particularly when matters are on hold due to criminal proceedings.
• Continuing to work with co-regulators and other agencies to strengthen our engagement and information sharing, including close work with Ambulance Victoria, Victoria Police and the Tasmanian Department of Health, and ongoing work with the Queensland Police Service.
• Building on the success and expansion of the Notifier Support Service to strengthen support for people who report sexual misconduct. A website hub is being developed for anyone who wants to report sexual misconduct by a health practitioner. Work also progressed on nationally consistent legal submissions outlining how Ahpra and co-regulators can advocate for notifiers and witnesses reporting in tribunal matters.

Supporting notifiers

The Notifier Support Service is staffed by social workers who provide emotional support to notifiers and witnesses and help explain how our notifications process works. It received 141 referrals and at 30 June had 214 open referrals.

An evaluation of the service has been running, which combines program data and interviews with victim survivors who have finished engaging with the service. It is designed to understand their experiences and the impacts of the service, and to inform service development.

In interviews, participants spoke highly of the service, highlighting flexibility and quality communication from social workers, and reinforced the need for beginning-to-end support during sexual boundary notifications. The evaluation found that participants felt supported in three main ways:

• Social workers gave participants process information, updates and an idea of what was coming next. This helped them feel more organised, focused and ‘on track’, and increased their understanding of the complaints pathway and their role within it. Reliable, proactive communication from the service helped participants feel that some of the mental burden of engaging with a notification was reduced.
• Social workers created a sense of safety and connection for participants, which resulted in positive feedback and warm reflections from interviewees. Participants spoke of how social workers met their emotional needs by remaining calm and normalising their feelings, which helped participants build rapport with the social workers. Social workers ‘holding space’ for participants – by giving time freely and listening actively – gave notifiers and witnesses the opportunity to feel heard.
• Connection with the service reassured participants that they had a support person who understood them and their needs and was ‘backing’ them. The physical presence of the social worker, such as at a tribunal hearing, gave participants confidence. A broader feeling that they were ‘not alone’ provided comfort to the participants throughout a challenging process.

These themes align with findings from other studies on supporting victims through similar processes.

How do we minimise the distress of regulatory processes for practitioners?

We plunged headfirst into a significant piece of work to implement the 15 recommendations and 33 related actions of the Expert Advisory Group (EAG). We have achieved a lot, with more to be done. Highlights include the following:

• Introducing pilot training in mental health and substance use disorders for staff and decision makers. The aim is to raise awareness of the risk of suicide and self-harm and improve understanding of practitioner distress.
• Reviewing the process for reporting serious incidents where practitioners and notifiers involved with us have attempted self-harm or suicide, or have suicided. We have been thoughtfully considering how to conduct reviews of these incidents in a safe and respectful way for everyone involved.
• Developing communication principles to improve our correspondence with practitioners and notifiers.
• Investigating the value and feasibility of a navigation and support service to guide at-risk practitioners through our regulatory processes.

Because the work of the EAG found that practitioners with a health impairment were particularly vulnerable, we are proud of the measurable progress we have seen in the way we manage health-related matters. There’s been a significant reduction in:

• requests by the National Boards for independent health assessments across notifications, compliance and registration where a practitioner’s treating practitioner is able to provide the information – this change has made the process less stressful and quicker, as well as more cost-effective
• the use of immediate action in health matters
• the time taken to determine health matters, with more matters being closed after action taken by the practitioner.

Collaborating with partners

We are excited about the emerging collaboration with external partners to help minimise practitioner distress. Some recommendations rely on the contribution of external partners.

In February, we held three day-long symposia. Support services, mental health organisations, professional associations, peak bodies for education providers, indemnity providers, legal defence firms, the health practitioner ombudsman and co-regulators, as well as Ahpra and National Boards representatives, met to collaborate on minimising practitioner distress. The focus was on two actions: working with external stakeholders to address myths and misinformation about notifications, and encouraging practitioners to seek support while involved in a regulatory process.

An extraordinary willingness to engage and collaborate on change was evident at the symposia. Many novel ideas were suggested over the three days and a variety of activities are underway by external groups, Ahpra and the National Boards. Here are just three examples:

• The National Boards deciding to create education modules on regulation and professionalism for students (one for nurses and midwives and another for all other professions), building on those published in 2023 for medical students. The aim is to build confidence among students in understanding regulation rather than fearing it.
• Developing short, engaging videos of doctors, nurses and other health professionals talking about their experiences of going through a notification. These are on the Ahpra website and published across social channels to address the shame and stigma while encouraging practitioners to seek support.
• A group of symposia attendees are collaborating on user-friendly FAQs about the notifications process, which will be distributed to a variety of external stakeholders to ensure that accessible, easily digested information is available.