In 2010, Australia took a monumental step forward in its approach to health care regulation. Regulators who previously operated on state- and territory-based licensing arrangements chose to consolidate all the country’s health regulation agencies into one national office: the Australian Health Practitioner Regulations Agency (Ahpra). At the helm of this transformation was Martin Fletcher, a leading health care regulator and now the 12-year CEO of the agency.

Today, Ahpra regulates roughly 840,000 health practitioners across 16 different professions in the country. The Australian model has offered a prime example of regulatory consolidation gone right, with licensed professionals in the country able to freely work where they are needed, regardless of state and territory lines. In our two-part interview series, Fletcher sits down with Ascend Magazine Editor Paul Leavoy to discuss his agency’s creation and the challenges of international health regulation at large.

What did Ahpra replace? What was regulating the health care professions like before its existence?

Ahpra came into existence on the 1^st of July 2010, and what it replaced was a set of profession-specific state- and territory-based arrangements for the regulation of health practitioners. A new single piece of national legislation was introduced, and it replaced something like 65 other pieces of legislation that had previously regulated those professions in different states and territories.

It created Ahpra as the national body to administer the work of regulation in Australia, and that was one organization that came out of 34 that had previously existed. Because we regulate 16 professions, it also created a multi-profession national approach to health regulation. In many ways, it was a transformational change – I used to joke at the time that it was probably so big you could see it from the moon.

When I reflect and look at reform of regulation around the world, it’s very rare to see transformational change in professional regulation. What you tend to see is incremental change, so it was unique in its size and scale and scope. Not without its challenges, I have to say, as you can imagine in such a huge change process. Now, 12 years on, we’ve very much established this part of the health structure within Australia

What were some of the drivers for the change? Why such a wide-scale consolidation of health care regulation?

There were three main drivers for the reform. First of all, some work had been commissioned by the state and territory and federal governments in Australia to look at future health workforce needs, and there was a concern that the way the regulation of health professions, being profession-specific and state- and territory-based, were set up in a way that created a barrier to flexibility that was needed to make sure we had the health workforce of the future.

Secondly, we’d had more than our fair share of well-publicized failures of regulation, so there was a concern that regulation needed to have a much stronger focus on public protection and patient safety at the heart of its work. And thirdly, we’d also had a series of natural disasters, wildfires, and bushfires in Australia, where it had been more challenging than it needed to be to mobilize health professions across state boundaries.

There are stories of medical boards having to open late at night just to license people to be able to come into that jurisdiction and assist with the emergency response. The fact that we didn’t have national mobility — i.e., the ability to register once and practice Australia-wide – was seen as crazy. Those drivers of workforce, patient safety, and mobility were the three main reasons why such a major change occurred in regulation in Australia

As I understand it, Australia has a kind of national mobility. Can you tell us more about how it works?

You register once and you can practice Australia-wide, within the scope of your registration. When I look at many of the younger generations of doctors and nurses and pharmacists who are coming up and being registered, I don’t think they could imagine a time when they would have had to register in different states and territories to be able to work in different parts of Australia. I think the fact that we have that national mobility has been a huge part of creating greater flexibility in our workforce and allowing people to move around to meet various health needs around the country.

There are plenty of movements across North America advocating licensing mobility, with plenty of proponents. But we also see many critics. What kinds of challenges did you encounter trying to consolidate and universalize this licensing system?

There was a concern early on that there might be a race to the bottom – in other words, the lowest standard in any state or territory would be the one that was applied and picked up across Australia. In fact, the opposite happened. This was a process that was, of course, politically led, because it needed all the ministers to agree. What actually happened, by and large, was the highest standard in any state or territory for any profession becoming adopted.

So, not only did we achieve national mobility, but we also achieved a greater focus on patient safety through that increasing standard. I’d also highlight that key role of political leadership, because ultimately, for us to come into being, all the states and territories had to pass the legislation. They all did, but of course, they needed strong political leadership to realize that vision and to see that legislation through.

In the early years, we faced a lot of challenges in getting down a very new and different way of working. I think it’s been worth it for Australia. Like many countries, we’ve had huge pressure on our health system in the past two years in response to COVID-19. We’ve been able to stand up a surge workforce that is available to work anywhere in Australia, and without needing to worry about removing licensing requirements or getting special licensing requirements for people to work where they’re needed.

Did you find it was overall a bipartisan or multi-party-supported endeavor? Before Ahpra was founded, was there across-the-aisle support for it?

There was both strong political leadership and strong political support, and what this involved was all of those health ministers around the country meeting very regularly. There was a particular state health minister who took the leadership role in relation to shepherding us through and working through the issues, but it was characterized by incredible cooperation and collaboration. We had a sense that this was the right thing to do, particularly around national mobility (and in the face of some of those terrible natural disasters we had in Australia), but we also understood the reform had to place patient safety and public protection much more strongly at the heart of regulation.

What about institutional resistance? Wherever you look, regulatory bodies do have a sense of themselves as the shepherds or gatekeepers  to a profession, and they can be resistant to change. Was that much of a factor?

There was a lot of consultation with stakeholders. We simply had an idea that had been talked about for many, many years. In the end though, all the governments signed a sort of in-principle agreement, and then there was a period of work over a couple of years to sort through all the detail of the reform, get the draft legislation together, and then get it through each of the parliaments. It’s fair to say there were probably reform areas that didn’t survive that process, and there was consultation and compromise and discussion.

One of the points I’d make is that regulation needs to continue to evolve, and one of the things that we’ve done, even since July 2010, is continue to get amendments to our legislation to continue to make it fit for purpose. We also continue to ensure that it’s relevant to where we are now in terms of the health system and what regulation needs to be able to do. In a sense, I would see reform of regulation as a big-bang approach, but then there’s that continued reform. For example, we’ve got a major package of amendments that will go through in the next year that will continue to equip us with the regulatory tools we need to do the best possible job we can.

What kind of elements are in this regulatory package?

One reform that I think is going to be important for the public is that it will be possible on our national register for a health practitioner to include a name that they’re now known as. One of the things we find in Australia, sometimes, is that people may anglicize their name or work under a slightly different name from what their official name is and what they’re registered in.

So, members of the public go onto our website and can’t find them, because that’s not the name they know them by. The fact that you’ll be able to not only have your official birth name but also the name you’re known as on the register will be an important public protection measure and it will make our national online register much more useful.

As I said earlier, we’ve got over 840,000 registered health professionals in Australia. Every single one of them is on our national online register, but we’re very aware of the fact that the register is probably something that many in the community aren’t aware of, and we think it’s an incredibly important asset. Anything we can do to make the register more useful for the community and choices they’re making about their healthcare is great. That’s one reform that I think is going to make a huge difference.

I understand that the U.K. did something similar in terms of consolidating health care regulation. Do you use its model to inform your approach in any way?

We’ve looked closely at what’s happening in the U.K. We’ve also been interested in developments in Canada and the U.S. and New Zealand. Though we often have quite different systems of health care or different arrangements for how we regulate health professions in different countries, there are a lot of common challenges. In the U.K., we’ve particularly looked at the Health and Care Professions Council (HCPC), which is an example of another multi-professional regulator, and been very interested in their experience of how they’ve developed multi-professional approaches to regulation.

One of my reflections on the past 12 years is that when Ahpra first started, and when I first started as CEO, when we kicked off the new arrangements, each of the professions that we regulate (medicine, pharmacy, dental, and psychology, for example) were very clear on the ways they were different from others and had very specific and unique regulatory needs. Over the past decade, there has been a recognition that there’s a lot more in common across the professions than perhaps people had first realized.

I can give you an example: we’ve just released a new code of conduct which is common across 12 of the 16 professions that we regulate. Of course, there are always going to be different unique features of different professions and different risk profiles and different professional characteristics. But at its core, this code of conduct – which sets out the expectations of the behavior of health practitioners – was common across these 12 professions, and I think that makes a lot of sense to the community as well.

If you ask the community, “why would we expect something different from a podiatrist than what we might expect from a psychologist, or a pharmacist?” I think we’d say we expect a common core of the way they behave and the way they treat patients and deal with people. Another part of our story over the past decade or so has been that strengthening of multi-profession approaches.

What we’re seeing in health care systems everywhere is an increase in team-based approaches to care and multi-disciplinary work into professional education and practice. I think anything we can do to strengthen those multi-profession approaches, recognizing that there will be distinct features of different professions, has got to be a good thing in terms of that wider approach within the health system.

Is there anything you’d advise regulators in Canada or the U.S. as they start to consider consolidation of regulation a little bit more seriously?

I’m always a little bit careful to be giving advice to others because there are unique features to different countries. I suppose I’d probably highlight a couple things. Firstly, I think I would suggest being clear on the goal of reform and what it is you’re trying to achieve. As I say in our case, we had some very clear drivers around mobility, around patient safety, around the workforce needs of the Australian health system, so I think that gave a very strong focus to the reform that we have.

Just to highlight how that played out in our legislation, which created governance and Ahpra and created the National Registration and Accreditation Scheme, not only did we have objectives around public protection and patient safety, but we also had objectives around workforce and the role of regulation in enabling the workforce that Australia needed for the future. I think being clear on the goal of the reform is important.

My second reflection would be to pay attention to implementation. As I said, it was a huge change for us. It was a big-bang change. We literally turned the lights off at midnight on a whole set of arrangements that were occurring around Australia and turned on the lights on a new one at one minute past midnight. It was incredibly challenging, the implementation. I’ve always wondered, “should we have taken longer to work through all of those issues and delayed starting?” I’m in two minds about that, because I suspect if we had, we may well still be here, going about all the complexities of it.

In some ways, I think on these big reforms you’ve just got to jump in and try to pick up the pieces and make it all work as quickly as you can. But that first year in particular was incredibly challenging because everything was new – new staff, new organization, new legislation, new systems, new forms, new requirements. It was enormously challenging, so I’d say pay attention to the implementation of any reform and regulation. You’ve got to balance getting it done with paying appropriate attention to the detail of what you’re trying to achieve. So, goals and implementation are probably my two reflections.

Ahpra has caught notice in other jurisdictions that rely on a more patchwork approach. Have you ever been approached by others from around the globe who are doing research and collecting best practices and lessons about such an endeavor?

There’s been quite a lot of interest in the model in Australia, as you say, because it is national and it is multi-profession, and we’ve certainly over the years talked to colleagues, particularly in Canada, the U.S., the U.K., and New Zealand. As much as people have been interested in learning from our experience, we’ve been really interested in learning from the experience of others and we’ve created an international collaboration to have a focus for some of that continued dialogue, because there are many common challenges.

We’ve also in the past few years been designated as a World Health Organization (WHO) collaborating center for health practitioner regulation. That’s got a particular focus on the western Pacific region. What we’re trying to do there is share our knowledge and expertise and tools and experience to really help strengthen some of the regulatory systems in the region.

Of course, we’ve talked about mobility within Australia, but the other feature of mobility for many countries is international mobility as well – the movement of health practitioners from country to country. So, I think we’ve certainly seen ourselves as wanting to play a role in helping to strengthen some of those systems where we can, particularly in countries that are source countries for people seeking to come work as health practitioners in Australia.

When you look at international collaboration, what do you see as an ideal vision of the future? Is it a place where an individual can seamlessly, for example, travel from New Zealand to Australia and practice effortlessly with common standards between the two locations?

That’s certainly one model, and we have something with New Zealand in place now called Trans-Tasman mutual recognition that does allow many health professions to be able to move fairly seamlessly between the two countries, and there’s a recognition of the licensure requirements between the two countries. But more widely, I think one of the things that has been a feature in Australia is the development of several free trade agreements with different countries around the world.

We’ve just recently signed a principal loan between Australia and India, for example, and what they often refer to is greater freedom of movement of professions (not just health professions, but professions more widely) as part of a wider trade agreement. We certainly think that that’s an area for us to be engaged in, to look at making sure we’re on the right footing in terms of the comparability of qualifications.

In Australia, we’ve traditionally been a country that is quite reliant on international medical graduates, so we have a steady stream of international medical graduates coming into Australia most years. Obviously, that has been impacted over the past couple of years with COVID-19, because Australia had its borders closed for an extended period.

One of the issues we face in Australia is although overall we have a pretty good supply of medical practitioners – we have about 130,000 registered medical practitioners in Australia – we have a major issue with distribution and there are many underserved areas particularly in remote regional and rural areas. So, we tend to see the concentration within larger urban areas. That might be an issue that’s common in Canada as well.

Traditionally, what’s often happened is those international medical graduates come to Australia but on the basis that they’ll go work in an area where we are currently underserved in terms of medical practitioners. That has been quite a big focus for us, to make sure those graduates are on the one hand up to the appropriate standards, but on the other hand, they are going into some challenging practice areas, so we want to make sure they are supported, have appropriate supervision and the like, as well as the supports they need to be able to work well in those more rural and remote regional areas.

I’m glad you brought up the WHO Collaborating Centre for Health Workforce Regulation – I understand you got involved with that in 2019. Can you tell me a little bit more about how it allows you to interact and collaborate with international colleagues?

It’s an important framework for us to be able to collaborate with others in the region. We work with WHO through their western Pacific regional office in Manila to agree on a workplan and priorities – for example, one of the major areas of focus for us in this collaboration is we’ve established a virtual network where we invite policymakers, people involved in regulation, and other interested stakeholders to come together virtually on a regular basis.

We use that as a mechanism for information exchange, just to really try to create dialogue and collaboration across the region, particularly for countries that have got embryonic or still-developing systems of professional regulation, where the agenda is about how to strengthen that system, often in the context of wider goals they’ve got around universal health care and access to health care and the like. It’s fair to say, like everything, it’s been impacted by COVID 19 over the past two years, so that’s been a major focus for several countries.

In one of the other areas, we saw ourselves potentially offering some form of technical support to countries – for example, hosting countries that might want to come spend some time with us to see how our system works, but also potentially being able to go into countries and provide advice and support for areas where they’d like to strengthen their regulatory systems. So that focus on developing that collaborative network, that information exchange, and those relationships has been major for our work in the collaborating center.

We’ve discussed how Australia’s national system for regulating health practitioners differs from many international models. In what other ways does it stand out?

One of the areas that’s most commented on when we talk to regulators in other countries is the fact that we don’t regulate scope of practice, we regulate title. In other words, what we regulate are the requirements for you to call yourself a registered medical practitioner or a registered psychologist or whatever the profession might be, with the exception of a very small number of what are called “protected practices.” There are international laws, for example, that you must be an optometrist to dispense glasses, or that you must be a dental practitioner to remove teeth.

We don’t regulate the scope of what a health practitioner can and cannot do – we regulate the title they use, obviously with the expectation that people will work within the scope of their education, training, and skills. That is a very different feature, often, from other regulatory systems, where the regulator focuses on the scope of what a health practitioner can and cannot do. If I link that back to the genesis of Ahpra and the National Registration and Accreditation Scheme, what it reflects again is that workforce driver. There was a view that regulation shouldn’t be a barrier to innovation and reform in what health practitioners can do and the health workforce needs of the future. In fact, it should be an enabler of that reform and, say, hence, that focus on title protection rather than regulating scope of practice.

Read part two of our interview series with Ahpra’s Martin Fletcher, where we discuss international government cooperation more in-depth and touch on the regulatory impacts of the COVID-19 pandemic.