Prior to the introduction of the National Registration and Accreditation Scheme (NRAS), arrangements for the regulation of the health workforce differed between jurisdictions and between professions. Flowing from the Productivity Commission’s 2005 research report Australia’s Health Workforce, the Council of Australian Governments (COAG) agreed to establish NRAS in March 2008.
NRAS commenced on 1 July 2010 with the passage of parallel legislation in each state and territory: the Health Practitioner Regulation National Law 2009 (the National Law). The scheme initially included practitioners in ten health professions –chiropractic, dental practice, medicine, nursing and midwifery, optometry, osteopathy, pharmacy, physiotherapy, podiatry and psychology. A further four professions were included from 1 July 2012 – Aboriginal and Torres Strait Islander health practice, Chinese medicine, medical radiation practice and occupational therapy.
National registration is intended to provide consistent standards for training, registration and professional conduct across Australia, and transparency through a national public register of practitioners. There is a national registration board for each participating health profession which develops the registration standards, guidelines for best practice and registration procedures, accredits training courses and develops the criteria used to assess applications from overseas trained practitioners. Under the National Law, the National Boards are overseen by the Standing Council on Health (SCoH). The responsibilities of the National Boards include:
- Registration of health professionals, including specialist registrations;
- Accreditation standards for courses of study leading to professional registration, including the requirements for clinical training;
- Developing registration standards, such as scope of practice, continuing professional development, insurance, and recency of practice, for the approval of SCoH;
- Developing policies, guidelines and codes for the guidance of their profession; and
- Investigating and acting on breaches of professional standards and conduct.
In most professions regulated under NRAS, the accreditation function of the National Board is undertaken by an external accreditation authority, such as the Australian Medical Council (AMC) or the Nursing and Midwifery Accreditation Council.
It should be noted that NRAS itself is not the only regulatory arrangement for Australian health practitioners. Health practitioners covered by NRAS are also bound by jurisdictionally-based drugs and poisons legislation, the scopes of practice determined by their employers and codes of conduct enforced by the relevant professional associations. There are also a number of allied health disciplines that are not part of NRAS, some of which have expressed a strong interest in being included in the scheme.
The introduction of the national scheme was intended to assist health professionals to 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.
Perhaps inevitably, with the establishment of a new organisation and the need to merge fragmented legacy databases from jurisdictions, delays and administrative issues were experienced at the outset. This has left residual concern within some regulated professions. Discussions with professional representative organisations and education providers generally indicated support for NRAS as a substitute for the previous state and territory registration and accreditation boards, panels and agencies. However, concerns clearly remain about delays, rigidity and obstacles to the re-entry of health professionals to the workforce.
Unanticipated issues have arisen which may be impeding the ability of some health practitioners to provide the full range of care allowed within the relevant professional scope of practice. These include the application of national registration standards and arrangements for prescribing.
Other issues to be considered within the context of the new scheme include collateral impacts on unregulated professions, the collection and availability of data, and the potential for the intensification of professional demarcation barriers.
Health profession national registration standards
Attraction and retention of already qualified health practitioners is important not only to the delivery of quality care to clients but also to the sustainability of the health workforce through mentoring and support for new and less experienced practitioners.
The health workforce grapples with an ever-changing environment of client needs including increased acuity of illness, growing prevalence of chronic health conditions, and an ageing population and workforce. To support this, a framework has been developed by each health profession’s National Board comprising registration standards for recency of practice and continuing professional development with complementary policies for re-entry to practice.
In some instances, a national approach has seen the introduction of standards into jurisdictions where none previously applied, with occasional unintended consequences. For example, the introduction of requirements for recency of practice in the nursing and midwifery profession and the associated re-entry policy of the Nursing and Midwifery Board of Australia have led to flow-on issues in New South Wales. In this jurisdiction, which did not previously have any requirement to maintain recency of practice, there was only one pre-existing re-entry course which has become over-subscribed.
Also, the introduction of a requirement to undertake degree level study for nurses and midwives who have been absent from the workforce for greater than ten years has created a significant disincentive for some individuals returning to the workforce. This is particularly noticeable when compared to other health professions without such requirements. Some experienced former nurses, particularly those with family responsibilities in rural areas, who are seeking to return to the workforce describe the new regulatory regime with a sense of great frustration.
As another example, psychology interns in some rural areas describe barriers to meeting the newly imposed requirements for general registration without undertaking clinical placements outside of their region. In common with other rural health practitioners, this can be a significant challenge to students who are studying part-time, with impacts on women with family responsibilities and other key demographics.
The introduction of a national scheme has also highlighted some inconsistencies between professions in certain registration standards, including requirements of recency of practice and continuing professional development. For example, the recency of practice standard for nursing and midwifery requires members of that profession to practise for a minimum of three months (full-time equivalent) in the previous five years to maintain registration. The standards for some professions such as medicine and physiotherapy, while including a requirement for recent practice, do not stipulate minimum levels.
Whilst all participating health professions commend the promotion of improved quality of care provided to the Australian community through national requirements for each of the regulated professions, some practitioners (particularly those outside metropolitan areas) have described difficulty in meeting the registration requirements around continuing professional development (CPD). In some instances, it was suggested that this may be due to a lack of CPD activities using flexible delivery arrangements.
The Government has provided funding for enhancements to flexible learning arrangements, particularly through the Rural Health Education Foundation (RHEF) which manages the new Rural Health Channel on the VAST digital network. Additionally, it is hoped that the Government’s National Broadband Network initiative will further enhance the opportunities provided by the Rural Health Channel, which has significantly expanded the reach of digital health education content.
The Rural Health Channel is a nationally available free-to-air health TV channel and began broadcasting on 21 May 2012. The Rural Health Channel broadcasts professionally accredited programs as well as health education information from providers such as government, professional organisations and health associations. This service provides an effective, regular and targeted communication to health practitioners in rural and remote Australia. This service was well accepted by rural and remote stakeholders spoken to in the course of this review.
In summary, whilst the differing clinical requirements of the health professions are recognised, the current regime runs the risk of escalating rigidities, particularly presenting barriers to re-entry and for ongoing registration of rural practitioners. To this end, continued Government investment in technology enabling remote education, training and supervision is highly valuable.
A range of health professionals currently prescribe medications in Australia, including doctors, dentists, midwives, nurses, optometrists, Aboriginal and Torres Strait Islander health practitioners and podiatrists. However, authority to prescribe is determined by state and territory drugs and poisons legislation, and there are differences between the jurisdictions in terms of the professions authorised to prescribe, and the conditions under which they can do so.
This creates a barrier, for some professions, to the benefits of workforce flexibility and mobility that have been delivered with the introduction of national registration.
As an example, the lack of harmonisation between state-based poisons legislation was raised by stakeholders in relation to Aboriginal and Torres Strait Islander health practitioners. In the Northern Territory, the Poisons and Dangerous Drugs Act allows for Aboriginal and Torres Strait Islander health practitioners to possess and supply medications if they have been approved to do so by the Chief Health Officer. However, there are no similar provisions in the other states or the ACT.
Health Workforce Australia (HWA) has been undertaking some work in this area with a view to advancing a nationally consistent approach to prescribing by health professionals other than doctors. The Health Professionals Prescribing Pathway (HPPP) project is aiming to establish a common framework for all non-medical prescribers, covering prescribing models, education and training, registration, accreditation and safe prescribing practices.
In conjunction with the HPPP project, the National Prescribing Service has recently developed a Prescribing Competencies Framework which forms the standard for prescribing education.
HWA released the draft pathway in January 2013.39 Once finalised, HWA intends to seek endorsement of the HPPP from the SCoH.
While national consistency in non-medical prescribing cannot be achieved without changes to state-based drugs and poisons legislation, the work of HWA on developing a national prescribing pathway is a step in the right direction to support further reform in this area.
The unregulated professions
Several unregulated professions have made strong representations in the course of this review, expressing a desire to be included in NRAS, and raising concerns about the decision of Health Ministers to limit consideration of national registration for any additional professions. They perceive that this has had an unintended consequence of stratifying the allied health professions into those which are nationally regulated, and those that are not; with associated concerns about loss of professional status.
An impression has been created that some professions receive greater support from Government. This was an issue raised by the Australian Association of Social Workers during the consultation process for this review, who was of the view that some agencies, including some Medicare Locals, were contracting only with registered professions to deliver services which had previously been delivered, for example, by social workers.
The Department has confirmed that mental health programs including the Access to Allied Psychological Services (ATAPS) and the Mental Health Services in Rural and Remote Areas fund services provided by both nationally regulated and unregulated mental health professions including psychologists, social workers, nurses, occupational therapists, and Aboriginal and Torres Strait Islander health workers. If a de facto situation has arisen that the registration status of a profession is being used to determine eligibility for service provision in a way that it was never intended, it may be timely to clarify this with Medicare Locals and other service providers.
Collection and availability of data
The introduction of a national system has enabled the collecting of detailed demographic information as well as information about geographical location and area of professional practice. The publication of standardised reports by each health profession’s national board on a quarterly basis has overcome some of the past difficulties arising from a lack of available data. However, on a cautionary note, the Australian Institute of Health and Welfare (AIHW) has voiced concerns about the quality of much of this data and would prefer that any barriers to direct interrogation of AHPRA data by AIHW should be removed. Given the expertise of AIHW this would seem a far less costly option than AHPRA continuing to build up its own data expertise; with consequent benefits in reducing the rise in registration costs.
Unlike the medicine, nursing and midwifery professions (which have a very substantial basis in the public hospital system), many allied health practitioners operate in the private sector using a small business model. This has limited the ability of health workforce planners and professions to obtain reliable information about their geographical location and professional areas of practice, and to design and target workforce measures to address gaps in service delivery, particularly outside of metropolitan areas.
Further discussion regarding the collection and analysis of health workforce data is included in Chapter 9.
|Recommendation number||Recommendation||Affected programs||Timeframe|
|Recommendation 3.1||The Commonwealth via the Standing Council on Health (SCoH) should engage with the national health professional boards to develop sensible and more consistent requirements for continuing professional development, recency of practice and re-entry to practice. Ideally, this should be undertaken for all registered professions and focus on maximising access to health services while maintaining safety and quality for the community. Professional re-entry requirements in particular, should be subject to periodic review for unduly onerous requirements creating barriers, particularly for the regional workforce.||Nil||Medium term|
|Recommendation 3.2||The Commonwealth should seek that SCoH bring forward options for a common legislative framework for prescribing of medicines by non-medical health professionals to promote workforce productivity, flexibility and mobility.||Nil||Medium term|
|Recommendation 3.3||The Commonwealth should identify and address any possible barriers to unregulated professions participating in Australian Government programs, where appropriate.||Allied health programs and scholarships.||Short term|