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Concerns raised about lack of regulation of the health workforce

Jon Wardle writes:

On August 5 the Australian Health Workforce Ministerial Council (AHWMC) met in Darwin and suggested that, as they had commissioned work on unregistered professions and future directions for national registration, they would defer the consideration of other profession into the National Registration and Accreditation Scheme (NRAS).

Ministers then agreed that it would be ‘premature’ to consider further applications of additional applications for the scheme until this work has been completed, other than paramedics.

This statement is rather disingenuous. Their consultation on unregistered practitioners did not even include an option for consideration of currently unregistered professions, only including leaving the status quo, supporting self-regulation or introducing negative licensing legislation (a statutory code of conduct).

The inclusion of paramedics is also interesting. They have been forced through in large part due to the tub-thumping of Kim Hames, Western Australian health minister and current Chairman of the AHWMC.

Now of course paramedics are very likely to warrant statutory regulation, but what is unfortunate is that personal patronage and politics, rather than public health consideration, seems to be the primary consideration when determining which professions will be included in NRAS.

For example, it can hardly be any less ‘premature’ to consider paramedics over other professions, particularly as no formal assessment against Australian Health Ministers Advisory Council (AHMAC) criteria for their inclusion has been made. In fact, the process for paramedics is far less mature than at least one profession.

Since 2007 AHMAC/AHWMC have been sitting on a Victorian government report that formally assessed the professions of naturopathy and Western herbal in accordance with AHMAC criteria and found that statutory regulation was warranted. The ordinary process after such an assessment is to conduct a Regulatory Impact Statement and Cost-Benefit Analysis on regulation of these professions.

However, to the relief of the cowboys in these professions, this happened to occur right at the time the NRAS was being rolled out, and action on the report was repeatedly delayed and deferred. Standards in those professions have predictably declined considerably as it became more apparent there would be no enforced minimum benchmarks.

However, public utilisation of these therapists has actually increased considerably – 16% of Australian women with cancer use a naturopath and they provide twice as many consultations as any other unregistered practitioner group.

It leads to an interesting conundrum; AHMAC/AHWMC has determined that the same herbal medicines are risky enough to require regulation of their use by Chinese herbalists, but not when they are used by Western herbalists or naturopaths.

Current process encourages self-interest

In truth the entire process of professions ‘applying’ for consideration to be included in AHPRA is a farce. It encourages representatives from professions to apply for their own interests. This was 21 professions, at last count, and most had done so to increase recognition more than to improve standards.

Most representatives from the only professions to have been formally assessed by a government to actually warrant regulation have in fact opposed inclusion. They are doing very well, thank you very much, from the unregulated nature of their professions.

One of the largest associations has even gone on to create a new ’50 year old’ fake registration body to muddy the waters, and giving the impression of further legitimacy, without needing to implement any of those bothersome accountability measures or standards that legislation would impose.

The process is even more farcical when it is considered that since 2008 persons such as myself were assured by representatives of AHMAC, governments and later AHPRA that an independent formal process of assessing currently unregistered professions would be the ‘third stage’ of the process (immediately after conclusion regulated and partially-regulated profession phases), this line only being dropped this year.

If we continue to treat practitioner regulation as some sort of prize that professions need to aspire to as to reach their full potential, it will never properly fulfil its true role for strengthening consumer protection.

The current situation is unworkable. Consistency, flexibility, transparency and independence need to be infused into the way that AHPRA evaluates professions for inclusion. AHMAC need to extend their unregistered practitioner program to institute a formal – and fully independent – process that determines which professions should be considered for inclusion in the scheme.

Negative licensing not enough – need more than ‘all or nothing’

Make no mistake, the unregistered practitioners negative licensing legislation is a world-leading reform. But it is no replacement for ‘real’ regulation, and AHMAC are ignoring their responsibilities to the broader public by suggesting it may be.

It is an excellent ‘catch-all’ for the worst offenders that prey on patients. It offers no proactive protection – unless you’ve been sexually assaulted or grievously harmed physically, there’s not much the negative licensing legislation can do.

During the consultation process Kieran Piehm – head of the NSW HCCC who instituted the scheme on which the legislation is modelled – admitted as much when he said that they could do nothing about ‘minor’ offences like incompetence, malpractice, misleading claims or ‘small amounts’ of financial exploitation.

However, we need more than an all or nothing approach, and one that can bring accountability to new professions based on the public interest. A recent South Australian government report, for example, suggested that there needed to be more than just negative licensing in professions like naturopathy and counselling (the two it specifically identified) to ensure minimum standards in those professions.

As the healthcare system reforms, many new professions will emerge, some requiring regulation (physician assistants, for example – if they can overcome their political hurdles). Some professions like social workers deal with vulnerable groups, and some may perform delicate or risky procedures such as speech pathologists or audiologists, and these too may need to be considered for further regulatory oversight.

Some professions may change their scope. Dieticians were previously supervised by registered professions in hospitals, but as more move into primary care and unsupervised practice, they may require further levels of accountability.

However, reports from those involved suggest the preferred option for AHMAC at the moment seems to be to defer consideration of new professions until 2014. That would mean, when realistically considering the process that go with inclusion, that any new profession included in NRAS would not be taking registrations until 2019!

As it stands, any profession immediately considered tomorrow would still be unlikely to be included before 2014-5.

There are many problems at AHPRA, and not just administrative. Some of the boards have gone, well, a little rogue, testing the new and unknown legislation to its limits to promote their professions’ interest.

AHPRA clearly needs to clamp down on some of these issues, but it shouldn’t be at the cost of deferring everything else. It already takes nearly five years to regulate new professions; they shouldn’t make it even longer by waiting five years before considering them as well.

AHMAC/AHWMC’s hesitance to include new professions hardly fits in with the NRAS legislative objectives to ensure a responsive, flexible and innovative approach to regulating the healthcare workforce.

• Jon Wardle is an NHMRC Research Scholar in the School of Population Health at the University of Queensland, and Director – Research Capacity Stream of the Network of Researchers in the Public Health of Complementary and Alternative Medicine

Comments 5

  1. Jenny Haines says:

    Personally, and there are many in the nursing profession who disagree with me, I think there needs to be a decision about the regulation of Assistants in Nursing, Aged Care Workers, and the many other titled roles that are essentially performing nursing work. While employers and governments may say that these workers are performing care work, at the same time they are being represented to consumers as nurses, and consumers believe they are nurses. Standards of education vary. These workers may have no education for the role at all, they may have a TAFE certificate, and now there are entrepreneurial schools of nursing offering certificates so that the holder can get a job in aged care. Who regulates what is being taught in these schools? Then the worker is regulated in the workplace by the employer, so the duties that they perform can be decided by the employer, subject to legislation and recommendations by Health Departments. When things go wrong in aged care, it is often assumed by the public, the media and politicians that the workers involved were regulated nurses, but that is most often not the case, and nursing is earning an undue bad name from unregulated workers.

  2. Sancho says:

    Can you clarify how assistant staff are being represented to consumers as nurses, Jenny? Many consumers make that assumption, no doubt, but in what way is it encouraged or endorsed?

    Healthcare operators have an obvious interest in being opaque about the qualification and scopes of practice of staff, which is the lack of registered nurses to meet the requirements of a first-class health system. If someone walks out of hospital satisfied with the care they received from all the “nurses” there, then they won’t get stuck into the administrators and minister about thin staffing.

    Registered nurses themselves should perhaps be careful about calling for tighter regulation, because the AMA, the most powerful union in the country after the business council, is only too happy to shout about the healthcare apocalypse that will ensue if nurse practitioners become common.

    Any review of registration and demarcation will become an opportunity for the AMA to further entrench an archaic staffing model that hasn’t changed since the 19th century.

  3. Doctor Whom says:

    Registration only gives the sCAM practitioners and the Quackademics, involved in acupuncture, homeopathy, reiki, naturopathy and other faith healing, legitimacy in the eyes of the general public.

    They should be subject to the same rules on misrepresentaion as fortune tellers, clairvoyants and mystics.

  4. Jenny Haines says:

    An example – when things go wrong in aged care, the media writes about the nursing staff at the aged care facility, omitting to mention that the “nursing ” staff may be any one of the titled roles of nursing or care work. You can write letters to the media and on blogs until you are blue in the face, but no-one takes much notice, and the public believe that that incident was poor care by nurses

  5. Sancho says:

    Can you provide some examples of the media doing that?

    I’m not saying you’re necessarily wrong about the public perceiving all aged care staff as registered nurses, but I haven’t really seen much evidence for that. Additionally, IIRC most of the high-profile aged care scandals were the result of callous management, not incompetent care staff.

    The people who care most about the quality of aged care are the consumers and their families, who, in my experience, also have a very clear understanding of the system and who does what within it.

    Addressing public confusion about roles would be nice, but committing resources to regulating staff who have completed the assigned competencies doesn’t seem like a top priority.

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