Before the formation of the Australian Health Practitioner Regulations Agency (Ahpra) in 2010, the landscape of health care regulation in Australia looked very similar to that of, say, the U.S. and Canada today. Licensing arrangements were state- and territory-based, and roughly 65 pieces of legislation created the framework for regulation in these different states and territories.

Studies by the Australian governments had found these geographically based licensing arrangements were creating barriers to flexibility that would prevent the country from having the “health workforce of the future.” Health care officials were also facing criticism at the time for a handful of regulatory failures, which drew public attention toward the issue of patient safety.

Thirdly, the country had recently suffered a series of natural disasters which highlighted the need for further mobility for health care professionals, so they could practice where they were needed most. These drivers spurred a transformational change in Australia’s regulatory system, one that dwarfed the incremental change seen in most countries.

What is Ahpra?

The formation of Ahpra allowed for free professional mobility in health care between all of Australia’s states and territories. Physicians could now register once and practice Australia-wide within the scopes of their professions. It started with an in-principle agreement signed by state and territory officials and took years of collaboration to get legislation drafted and passed by both local and federal governments.

Today, Ahpra works collaboratively with 15 individual national health boards to assist them in protecting the public interest and the integrity of the health professions. The agency works with each of these boards to consolidate, coordinate, and centralize the standards and policies that health practitioners must meet to become members within the health professions.

In this regard, Ahpra’s reach extends to over 840,000 registered health professionals in Australia, all of whom are registered in a national online database. The agency has also taken strides to facilitate mobility for professionals from outside of Australia, often distributing these graduates to underserved areas while making sure to hold them to the appropriate standards of practice.

So, what does Ahpra represent in terms of regulatory centralization, and how does it offer a vision of the future to countries whose health systems are hamstrung by patchwork licensing arrangements and discrete health care service delivery systems and databases?

What is regulatory centralization?

Regulatory centralization aims to use top-down leadership to achieve better harmonization and consistency at the state and provincial levels. Critics of this trend in health care regulation point to a concern that the lowest common standards for quality of care will be adopted across the board. There also exists a concern that with the consolidation of multiple state-based arrangements into centralized regulatory bodies, these agencies will become too bureaucratic and slow to respond to emergent issues.

According to Ahpra CEO Martin Fletcher, however, these concerns in Australia were rather quickly disproven, as the highest standards of education and quality of practice were largely adopted across the entire country. Fletcher says the formation of the agency allowed Australia’s health care system to take a top-down approach to professional regulation – one focused on patient safety as its foremost priority.

Ahpra, though not a fully centralized regulatory body, offers an example of federal leadership gone right – a federal agency that collaborates with lower-level governments to maintain harmony between the health care environments of different states and territories. Its more federal approach stands in stark contrast to countries like the U.S., where multi-state cooperation is implemented a bit differently.

Centralization in the U.S.

Centralization at the state level

Some of the U.S.’s most notable examples of regulatory centralization can be found at the state level, particularly in the existence of “umbrella agencies,” which consolidate and cooperate with smaller boards to provide high-level oversight. A 2021 report from the Council on Licensure, Enforcement, and Regulation (CLEAR) provides a look into how these agencies operate in the 23 states in which they exist.

In Colorado, for example, the Department of Regulatory Agencies (DORA) manages licensing and registration for multiple businesses and professions in the state. Formed in 1968, the agency seeks to balance regulation and ensure consumer protection across many Colorado industries. With 10 divisions and over 312 board members, it regulates over 500,000 licensees, registrants, certificants, and permit holders in the state.

In Part 1 and Part 2 of Ascend Magazine’s recent Q&A with Ronne Hines, a former leader within DORA, we explored the agency’s founding mandate and the way it has evolved over the years. For example, DORA was responsible for the creation of a centralized complaint intake system to replace 50 pre-existing complaints processes (one for each program area). With a smaller team handling investigations on the front end for all 50 programs, complainants can receive resolutions in a timelier manner.

The Interstate Medical Licensure Compact

Though a statutory body like Ahpra has not yet been established in the U.S., due perhaps in part to the country’s political climate and culture, the demand for greater professional mobility can be seen in cases like the development of the Interstate Medical Licensure Compact, which first took shape in January 2017 with its adoption by 17 states.

This compact created a centralized licensure mechanism allowing professionals to practice freely across state lines. States could also now share licensing data with one another to streamline the process of certification. It has been particularly advantageous during the explosion of telehealth services in the wake of the COVID-19 outbreak, with professionals practicing across state lines daily.

Calls for stronger federal leadership

In June 2022, a panel of experts commissioned by the Commonwealth Fund published a report advising U.S. legislators to embrace a more centralized approach to health care regulation. Though it does not go as far as advocating for the establishment of an agency like Ahpra, the report calls for stronger federal leadership in how public health departments operate in the U.S. The group, comprised of former government officials and public health leaders, pointed at the U.S.’s failures in handling the COVID-19 pandemic as reason to overhaul its federal protocol.

“The consequences of these deficiencies reach far beyond the current pandemic and undermine the nation’s ability to respond to ongoing and pressing health challenges,” the group wrote.

Without strong federal leadership, the panel argued the U.S. would be ill-equipped to handle the next public health crisis or even respond to current-day priorities with the appropriate level of efficiency and competence. The group recommended Congress establish a federal health official to implement a national public health system.

It also suggested the implementation of a modern public health information technology system, pointing out that more than one third of local health departments cannot access electronic surveillance data from emergency departments, which would empower these departments to identify and respond to public health concerns more quickly. The suggestion includes a 10-year, multi-billion-dollar investment in these endeavors.

Lessons from the U.K.

The U.K., too, has created multi-professional regulators, most notably in the formation of the Health and Care Professions Council (HCPC) in 2001. Today, this agency regulates 15 different health and care professions, including biomedical scientists, operating department practitioners, and podiatrists. The steps taken to form the Council offer a useful roadmap for regulators looking to centralize their work.

For one, the Council was preceded by a Shadow Council which outlined its intention to establish standards in four key areas:

• Standards of education and training.
• Standards of proficiency, which described the skills and knowledge of the profession.
• Standards of conduct, performance, and ethics.
• Standards of continuing professional development.

Several committees were also formed to ensure these standards were enacted thoroughly and fairly throughout the country, including the Education to Training Committee and the Fitness to Practice committees. In addition to Council members, many HCPC “partners” – laypeople and professionals alike – were recruited from fields related to the health and care professions to ensure those with knowledge of these professions were involved in regulatory decision-making. By 2015, the number of partners involved with HCPC had risen to 824.

Paying attention to implementation

Centralizing health care regulation in any given country can offer many potential advantages. Done right, it can allow regulators to ensure consistency in their decision-making and reduce duplication of effort as new standards struggle to be enacted across multiple jurisdictions. The creation of a uniform set of standards for a wide range of professionals across these jurisdictions can also simplify compliance and make it easier to enforce decisions around licensing and disciplinary measures.

What’s most important, according to Fletcher, is that implementation is closely monitored throughout every step of the process. Even the best-laid plans could go awry if the officials involved are not in constant communication. New problems will arise as times, standards, and practices change, and regulators must remain flexible with the legislation they attempt to pass and the measures they take to implement it to ensure the highest degree of public protection across the board.