1. 1 National Registration – ‘Reform extraordinary in its vision and scale’ Dr Phillip Donato OAM, Chiropractor Chair, Chiropractic Board of Australia Dr Paul Fisher, Chiropractor Executive Officer, Chiropractic Board of Australia

2. Outline... What did we have What was wanted What did we get – NRAS What have we learned ? What was extraordinary

3. BACKGROUND

5. Did you know... 5

6. 6

7. Australia today... We share our land with its indigenous people and we acknowledge their ownership and custody of this land. Total population 23.5 M, urban 89%, 6 per sqkm 25% resident population born overseas –UK 23% –NZ10% –China 6% –Italy 5% –Vietnam 4% –India 3% Median Age 37

8. Health Care in Australia... Australian Health Expenditure 9.1% GDP ( US 15.2%) 70% paid by Government, balance by Private and third party payers Health Insurance – mixed system Medicare – universal health insurance – Medical fees (partly covered), public hospitals, some Chiropractic Care Private health insurance – private hospitals and ancillary benefits Workforce One in 44 Australians – or one of every 20 working Australians - is a registered health practitioner.

9. CHIROPRACTIC REGULATION

10. History of chiropractic regulation… 1905 until 1960 Chiropractic - self regulated profession Chiropractic first regulated by own statute in Western Australia in 1964 Eventually all states and territories enacted laws to regulate the practice of chiropractic Significant variation in the style of legislation

11. Prior to June 2010... Legislation in each state and territory regulating chiropractors ( 8 sets of laws) Chiropractic Registration Boards in each state and territory (8 separate Boards) 1992 Commonwealth Mutual Recognition Act - to facilitate movement of registered professionals between jurisdictions ( same as Australia- New Zealand recognition model) Single Accreditation Council (CCEA Inc) Similar for all other regulated Health Professions

12. An environment of change... Increasing community involvement –Board membership – 1/4 to 1/3 lay members –Consultation re standards, guides Increased public access to information –About registrants, Board processes and outcomes Separation of powers – more serious matters heard in judicial tribunals Increasing transparency and accountability More oversight and scrutiny

13. The visions... The professions –National registration – driver’s licence model –National standards and consistency –Reduced fees The community –More information and transparency –More consistent regulation and accountability Governments –More workforce flexibility, mobility and capacity

14. NATIONAL REGISTRATION AND ACCREDITATION SCHEME (NRAS) (The combined vision)

15. The new scheme – NRAS... National registration and accreditation scheme (NRAS) for 1.The regulation of health practitioners 2.The registration of students undertaking clinical training in a health profession 3.Nationally consistent accreditation processes

16. Genesis... Concerns about health workforce shortages Concerns about workforce inflexibility and location Concerns about consistency of standards General need for reform 2006 - Productivity Commission - Australia’s Health Workforce – ‘Super Board’ 2008 – COAG - Agreed to develop a single National Registration and Accreditation Scheme for 10 professions

17. COAG... Council of Australian Governments Peak intergovernmental forum Prime Minister & State Premiers and Territory Chief Ministers To initiate, develop, monitor implementation of policy reforms of national significance which require cooperative action by Australian governments e.g. health, education, energy Aims to deliver ‘seamless national economy’

18. Development... July 06 - COAG announced NRAS – start July 08 “to facilitate workforce mobility; improve safety and quality; reduce red tape; simplify and improve consistency ” Mar 08 - COAG Intergovernmental Agreement single scheme, national agency, profession specific national boards, offices in each state/territory National Law Model – legislation enacted in one jurisdiction and then mirror imaged across states.

19. THE NATIONAL LAW

20. Legislation... Act A – The Health Practitioner Regulation (Administrative Arrangements) National Law Act 2008 (Queensland) Act B – Health Practitioner Regulation National Law Act 2009 (Queensland) - Full provisions for operation of the scheme to commence 1 July 2010 Acts C – Adoption and Consequential Bills in each jurisdiction – agreement to have in place by end 2010

21. Federation … in practice! JurisdictionLegislation passedJoined scheme Queensland 3 November 2009 1 July 2010 New South Wales19 November 2009 1 July 2010 Victoria 8 December 2009 1 July 2010 ACT16 March 2010 1 July 2010 Northern Territory17 March 2010 1 July 2010 Tasmania17 June 2010 1 July 2010 South Australia29 June 2010 1 July 2010 Western Australia19 August 201018 October 2010

22. 22 Before 1 July 2010 Eight States and Territories > 85 health profession boards 65 Acts of Parliament 85 sets of administration infrastructure After 1 July 2010 One national scheme 10 health profession boards National Law model Local variation in 3 jurisdictions One administration infrastructure

23. Health Professions involved... July 2010 chiropractors dental care (including dentists, dental hygienists, dental prosthetists & dental therapists), medical practitioners nurses and midwives optometrists osteopaths pharmacists physiotherapists podiatrists psychologists July 2012 Aboriginal and Torres Strait Islander health practitioners Chinese medicine practitioners medical radiation practitioners occupational therapists Future ?

24. Guiding principles... national scheme to operate in transparent, accountable, efficient, effective and fair way registration fees to be reasonable (having regard to the efficient and effective operation of the scheme) restrictions on practice to be imposed only if necessary to ensure health services provided safely and of appropriate quality

25. Objectives... Provide for protection of the public by ensuring that only practitioners who are suitably trained and qualified to practice in a competent and ethical manner are registered Facilitate workforce mobility across Australia Facilitate provision of high quality education and training of health practitioners Facilitate rigorous and responsive assessment of overseas practitioners Facilitate access to services in the public interest Enable continuous development of a flexible, responsive and sustainable Australian health workforce and enable innovation in education and service delivery

26. NRAS – what model of regulation is it? National regulation under national law Protection of title, not practice (some exceptions) Role of government more explicit (Ministerial Council) All jurisdictions, ten professions, one administration(AHPRA)

27. Does NRAS address the concerns? 27

28. THE NATIONAL LAW IN OPERATION

29. Government... Via Australian Health Workforce Ministerial Council May give directions to Agency or Boards including –about policies, administrative processes, procedures –about accreditation standards only if proposed standard will have substantive negative workforce effect and if first consider potential impact of direction on quality and safety of healthcare Approve registration standards, specialties, endorsements Appoints National Boards, Agency Management Committee, AHWAC May not give directions about particular person or qualification or application, notification or proceeding or codes/guidelines

30. AHPRA... Australian Health Practitioner Regulation Agency Ensures all functions are carried out in line with the objectives and guiding principles of the scheme Provides support and administrative services to National Boards and committees, through a National office and State/Territory offices Has own regulatory functions and responsibilities under the National Law Establish annual Health Profession Agreements with each National Board re registration fees and re services AHPRA provides Employ staff, enter contracts, manage property etc

31. National Boards... Appointed by Ministerial Council At least half and not more than two thirds practitioner members The chair is to be a practitioner member At least a third community members Members from each jurisdiction –Initial membership drawn from existing state and territory Boards Terms of appointment – 3 years

32. Role of National Boards... Set national registration standards, codes and guidelines Determining overarching policy Final approval of programs of study Oversee assessment overseas trained practitioners Oversee receipt and follow-up of notifications re health, performance and conduct Maintain registers (with AHPRA) Set registration fees and develop Health Profession Agreement with AHPRA

33. NRAS Structure... Ministerial Council Advisory Council National Boards Agency Management Committee Agency Management Committee National Committees National Committees State/ Territory/ Regional Boards State/ Territory/ Regional Boards National Office State and Territory Offices State and Territory Offices Support Accreditation Authorities Accreditation Authorities Contract Advice

34. Key features of the National Law... Broad consultation Categories of registration Registration standards Mandatory Reporting of notifiable conduct Voluntary notifications Student registration

35. Key elements of the National Law (continued)... Funding National registration fee for each profession Entire scheme self-funded from registration fees No cross profession subsidisation Accreditation Initial appointment by Ministerial Council

36. Registration Types... General Registration Specialist Registration Provisional Registration Limited Registration – Public Interest Limited Registration – Teaching and Research Limited Registration – Supervised Practice Student Registration Area of Practice Endorsements 36

37. Registration Standards... Criminal history English language proficiency Recency of practice Mandatory continuing professional development Mandatory professional indemnity insurance Limited Registration 37

38. Notifications... The National Law provides for both Voluntary and Mandatory notifications about practitioners and students. Mandatory notifications - practitioners and employers must report a registrant who they reasonably believe has engaged in notifiable conduct (some exceptions) Not limited to notifications in same profession Notifiable conduct defined as –practising while intoxicated by drugs or alcohol –engaging in sexual misconduct in connection with professional practice –placing the public at risk of substantial harm through impairment or poor professional practice.

39. THE NATIONAL REGISTER OF HEALTH PRACTITIONERS

40. 40 Profession ACT NSW NT QLD SA TAS VIC WA No PPP* Total Chiropractor 531,40924669351441,1034541804,287 Dental Practitioner 3305,6111203,5361,5683204,1242,07055818,237 Medical Practitioner 1,70627,64188116,7746,8772,03121,2718,2342,51787,932 Midwife 16320102293097631168901,780 Nurse 4,22678,8662,83954,62526,8817,54376,72528,2959,463289,463 Nurse and Midwife 71314,2855737,6412,62772610,3753,22335340,516 Optometrist 691,49629902209801,1003351954,415 Osteopath 3239421321937683531001,452 Pharmacist 3988,0571734,9151,8286006,2712,79267925,713 Physiotherapist 4186,5221314,1021,8243785,4192,60678422,184 Podiatrist 4589212568342801,076341323,388 Psychologist 7669,8842004,9971,4085017,5832,97036628,675 Total 8,772155,3774,99499,09044,24312,347136,36151,54115,317528,042 Registration data...

41. 41

42. Chiropractic data... StateGeneralLimitedNon-practisingTotal ACT51253 NSW13681401409 NT23124 QLD65415669 SA34011351 TAS44 VIC1065381103 WA4468454 Not supplied97183180 Total 408821984287 42

43. 43

44. SexStateGeneralLimitedNon-practisingSubtotalTotal FemaleACT23 2251503 NSW481117499 NT9 110 QLD200 5205 SA116 2118 TAS11 VIC388 14402 WA165 1166 Not supplied34 3367 MaleACT28 2779 NSW885 23908 NT14 QLD454 10464 SA224 9233 TAS33 VIC676 24700 WA280 7287 Not supplied62 50112 Not suppliedNSW2 2 VIC1 1 WA1 1 Not supplied1 1 5 Total 408811984287 44 Chiropractic data (cont.)

45. Current Registration data (cont.) 45 AgeGeneralLimitedNon-practisingTotal 20 - 25100 26 - 30613125639 31 - 35653 38691 36 - 40705 27732 41 - 45579 19598 46 - 50409 23432 51 - 55370 19389 56 - 60263 11274 61 - 65181 14195 66 - 70113 8121 71 - 7564 1074 76 - 8024 428 81 - 8510 86 +2 2 Not supplied2 2 Total408811984287

46. Age Demographics… 46

47. WHAT HAS HAPPENED AND WHAT HAVE WE LEARNED?

48. Differences practitioners notice... Registration fees – $528 AUD National registration Requirements for CPD, Recency, PII Mandatory reporting New codes, guidelines and registration standards Challenges in first few months

49. Differences the public notice... National Online Registers Consistent standards across jurisdictions Greater tranparency 49

50. Personal perspectives... Major and significant reform – right timing Turbulent and difficult gestation and infancy Extent of change process was underestimated –New legislation –New organisations in new offices –New systems and process including IT system Many experience sense of loss of identity, culture, history, status and felt disempowered

51. Significant benefits... National approach and consistency Will be springboard for reform and innovation Cross jurisdiction & cross profession learning and collaboration Eventual cost efficiencies Greater resourcing through large agency More online ( paperless) functions More detailed data mapping Better engagement and communication

52. Significant challenges To rebuild relationships and confidence To get all the people and systems working effectively together 52

53. Reflection... Monumental first few years Journey of extraordinary change Realisation of a vision Move towards regulatory excellence and reform More robust systems Stronger relationships Extraordinary achievement 53

54. Issues for the Chiropractic Board... Advertising Ensuring proportionate and timely responses to notifications Dealing with frivolous or vexatious - complainants and practitioners Building and maintaining the confidence of the public and the profession

55. …hopes for NRAS Respected by the profession, governments and the community Focus on safety and quality of healthcare and promote good practice Find the right balance between competing needs and views e.g. workforce Agile, able to identify & address emerging issues Transparent, accountable, efficient, effective, fair regulation

56. References 56 Morauta, L 2011, Implementing a COAG Reform Using the National Law Model: Australia's National Registration and Accreditation Scheme for Health Practitioners. The Australian Journal of Public Administration, 70 (1) 75-83 Commonwealth of Australia, 2011. The administration of health practitioner registration by the Australian Health Practitioner Regulation Agency (AHPRA). Senate Finance and Public Administration Reference Committee. Canberra Australia.

57. Any other issues? Questions? 57