What is ‘statutory registration’?
Statutory registration is a type of licensing scheme that is established under a law of a state or territory. An example is the National Registration and Accreditation Scheme (NRAS) under which the members of 16 ‘regulated health professions’ are registered to practise those professions in Australia.
What does a statutory registration scheme do?
The purpose of a statutory registration scheme is to protect the public by assuring the quality, safety and competence of registered practitioners. It establishes a regulator with powers to:
- set enforceable qualifications, probity and language proficiency standards for entry to practise in a regulated health profession and prevent unqualified persons from entering practice in that profession
- assure the quality of educational programs that qualify practitioners for entry to practise
- require registered health practitioners to demonstrate continuing competence
- deal effectively with registered health practitioners who do the wrong thing, that is, those who flout accepted professional standards of practice in ways that place their patients at risk of harm.
What is Ahpra?
Ahpra is the administrative arm of the NRAS – it provides administrative support services to 15 National Boards, including the Medical Board of Australia (MBA), the Osteopathy Board of Australia (OstBA), the Chiropractic Board of Australia (CBA) and the Chinese Medicine Board of Australia (CMBA).
It is these National Boards, not Ahpra, that make most of the statutory decisions under the NRAS – decisions such as to register a practitioner, to investigate a complaint about a practitioner or to take disciplinary action against a practitioner.
Each National Board is constituted with a majority of members from the profession the Board regulates. So most members of the Chiropractic Board are chiropractors and most members of the Osteopathy Board are osteopaths.
Further information on Ahpra, the National Boards and the NRAS is available here:
https://www.ahpra.gov.au/About-Ahpra/What-We-Do.aspx
https://www.ahpra.gov.au/Notifications/Further-information.aspx#
Why are many naturopaths and naturopathic professional bodies convinced that registration of naturopaths under the NRAS would be a good thing?
Statutory registration of practitioners operates to protect the public – by setting enforceable minimum qualification and probity standards for entry to practise in a regulated profession. A registration scheme effectively prevents unqualified or under-qualified people from entering practice without proper credentials. It provides strong powers to prosecute people who pretend to be qualified when they are not and enables unfit people to be removed from practice where they are a serious risk to the public. These are important milestones in the development of any health profession.
While the NRAS is designed to protect the public rather than promote the interests of a profession, statutory registration does bring benefits for those registered professions. This is because it promotes trust in the professions and provides important institutional recognition of registered practitioners.
For instance, we know that without an enforceable minimum naturopathy qualification, we have a problem with untrained and unqualified persons entering naturopathic practice. We also have no effective means of removing unfit naturopaths from practice. This brings our profession into disrepute, reduces community trust and makes some potential service users wary of seeking the services of a naturopath. It also makes our colleagues in other professions wary of collaborating with us because they have no reliable method of telling who is properly qualified. The registered professions have greater institutional recognition and benefits – they are more likely to have a seat at the table or to be consulted when important health policy decisions are made by governments. They are also more protected from decisions that adversely affect their interests. For instance when the Commonwealth Government decided in 2016 to remove private health insurance rebates for various complementary therapies (including naturopathy), the Chinese medicine, osteopathy and chiropractic professions were protected from this decision – they retained their provider rebate status under the private health insurance rules. Why? Although it was never publicly stated, it seems because they are registered and regulated under the NRAS.
Why do some believe that registration of naturopaths under the NRAS would be a bad thing?
There is a lot of misinformation about how statutory registration operates and what the profession might lose if it were to become a regulated health profession under the NRAS. For instance, we know some people fear they will lose their right to practise and therefore their livelihood because they hold older qualifications or qualifications that are less than bachelor’s degree level. However, history tells us that whenever a new registration scheme is introduced, the law provides for ‘grandparenting’ into the scheme of those already in practice, even if they don’t have qualifications that meet the new standard set. This is what happened with some of the more recently registered professions: Chinese medicine (where many of the most senior members of that profession trained as apprentices under ‘Masters’, long before tertiary qualifications were widely available) entered the NRAS in 2012; and paramedicine (some of whom trained at diploma level within state ambulance services) entered the NRAS in 2018. See detailed FAQ below on how grandparenting works.
Won’t we lose control over our own practice principles & standards?
Some people fear that the profession will lose control of its standards and that the important principles that underpin naturopathy as it is traditionally practised will be compromised or lost. Again, history tells us that this is not the case with other complementary medicine professions that are registered (Chinese medicine, osteopathy, chiropractic), or in other countries where naturopathy is a regulated profession (such as many US states and Canadian provinces).
Won’t we lose business with registration?
Some fear that registration will drive some naturopaths out of business. There is no evidence to support this. History shows that those complementary medicine professions that are regulated under the NRAS are continuing to thrive. While you will find diverse views within these professions about what it’s like to be regulated. However, given the choice, it would be rare to find anyone who supports returning to the days before they were a registered health profession.
What is ‘grandparenting’ and how does it work?
Every registration law enacted by a state and territory government has had provisions that empower the newly established regulator to set the qualification standard for new entrants to the profession, but also to provide a streamlined pathway to registration for those already in practice who hold older qualifications. This process of bringing existing practitioners into a licensing scheme at its commencement is known as ‘grandfathering’ or ‘grandparenting’ and usually operates for the first three years of the scheme. Grandparenting acknowledges that senior, knowledgeable and experienced members of the profession may have trained decades earlier, sometimes via apprenticeships rather than formal educational programs and that they have the right to continue practising despite the establishment of a new qualification standard applicable to new entrants to the profession.
For instance, when registration was first introduced for the Chinese medicine profession, the newly appointed Board issued a draft policy on grandparenting, and invited input from the profession about how it proposed to implement the grandparenting provisions of the new law. Taking into account feedback from the professional bodies, practitioners, education providers and other stakeholders, the Board then finalised and implemented the policy, registering practitioners who held a variety of diploma qualifications and apprenticeship training who could demonstrate a safe record of practice. Very few were refused registration and even fewer were asked to upgrade their qualifications. In 2018 there was also a grandparenting process to bring paramedics with older qualifications into the NRAS. We would expect the same thing to happen for naturopathy – that we would all have ample opportunity to have input into the proposed grandparenting arrangements before they are finalised and implemented and that naturopaths with older diploma level qualifications would be eligible for registration without having to upgrade their qualifications or do further training.
What are the chances that Governments will decide to include naturopaths in the NRAS?
History tells us that a government rarely decides to register a health profession on its own initiative – when a government does act, it is generally in response to decades of political pressure from the professional representative bodies concerned. See for example the new registration scheme for social workers in South Australia – the result of over 20 years of lobbying. Thus, we expect to have to work very hard to get the attention of government and to make the case for registration of our profession. But we believe it is an important step in our professionalisation journey and worth the effort, to better protect the public.
Is registration expensive?
Under the NRAS, the cost of registration varies depending on the profession. Because the system is funded principally by registration fees, the larger the profession the greater the economies of scale and the lower the cost of registration for each practitioner. Also, some professions (such as medicine and dentistry) are more expensive to regulate than others, so this pushes registration fees higher. According to the Ahpra website, 2022-23 registration renewal fees range from $154 for Aboriginal and Torres Strait Islander Health Practitioners and $180 for nurses, midwives and physiotherapists through to $860 per year for medical practitioners. For the complementary medicine professions, the 2022-23 registration renewal fees are $492 for Chinese medicine practitioners, $451 for chiropractors and $399 for osteopaths. With a registrant base of approximately 15,000 naturopaths (more than double the size of chiropractic, Chinese medicine and osteopathy combined), we would expect the registration renewal fee to be similar to other mid-sized professions such as paramedicine ($240) and medical radiation practitioners ($203).
Will registration increase professional indemnity insurance premiums for naturopaths?
There is no evidence to suggest that the introduction of a registration scheme increases the indemnity insurance premiums for a profession. Premiums are set by insurance companies based on actuarial data about malpractice claims. With a well-regulated profession, such payouts would be expected to decrease.
Some fear that statutory registration will prevent naturopaths from practising to their full scope of practice, undermine our traditional practice and require us to conform to the Western biomedical model of practice. How real is this threat?
There is no evidence that the traditional knowledge and practice of the Chinese medicine, chiropractic and osteopathy professions have been compromised as a result of registration of these professions.
Instead, by providing a strong institutional base for continuing practice, registration of complementary medicine professions serves to preserve and promote traditional knowledge and practices.
The World Naturopathy Federation supports statutory registration for the naturopathy profession. It has recently published a reporting showing that statutory registration of naturopaths is growing as more jurisdictions introduce licensing/registration schemes (Lloyd et al., 2021).
A recent review of the global literature on health practitioner regulation commissioned by the World Health Organization has found that stronger regulation of the traditional medicine professions may be warranted (Leslie et al., 2022). One rationale offered for stronger regulation is to preserve and promote traditional medicine practice. The evidence shows that statutory registration works just as well for the complementary medicine professions as it does for the conventional health professions (Leslie et al., 2022).
Statutory registration is underpinned by the principle of peer review. Under the NRAS, every regulated profession has a National Board that is made up of between 9 and 12 members, the majority being practitioner members from the regulated profession. Practitioner member positions on a National Board are advertised publicly and open to any registered practitioner from the regulated profession to apply. It is the National Board (comprising a majority of members appointed from the profession) that sets the registration and practice standards for the profession, not the government or Ahpra. The governance model ensures that it is Chinese medicine practitioners who set the standards for the practice of Chinese medicine and osteopaths who set the standards for the practice of osteopathy, and so on. In this way, traditional knowledge and practice is preserved and strengthened. In relation to evidence-based medicine, most of what the conventional health professions do does not have a strong evidence base. Naturopathy is no different. Like in other professions, naturopathic researchers are working hard to build the evidence base for our practice but this is not a prerequisite for registration.
How is scope of practice regulated under a statutory registration scheme? Would registration prevent naturopaths from practising iridology or homoeopathy?
It is not surprising that some are confused about how scope of practice is regulated under the NRAS, given the misinformation. The NRAS operates on the basis of ‘protection of title’, that is there are certain titles (such as ‘osteopath’ or ‘Chinese medicine practitioner’) that are reserved only for registered practitioners in specified professions. Unlike in some other countries, in Australia there are NO legislated scopes of practice for any of the registered health professions, nor do the National Boards publish scope of practice statements. There are a handful of ‘restricted acts’ in the National Law, that only registered practitioners from specified professions may carry out (such as some dental acts, prescribing optical appliances and manipulating the joints of the cervical spine). Under these arrangements, it is up to each registered practitioner to determine their own scope of practice, based on their training and competencies, the type of registration they hold and the requirements of their employer (if they have one). Most registered practitioners hold ‘general’ or unrestricted registration. The only practitioners under the NRAS who have a restricted scope of practice are those who have been granted ‘limited’ registration, for example, to undertake an internship following graduation, or those who have been subject to disciplinary action and conditions have been imposed on their registration to ensure they are safe to practise.
Will we be prevented from practising if we are not fully vaccinated for diseases such as COVID-19?
Ahpra has no power to require a registered practitioner to be vaccinated against COVID-19.
During the COVID-19 pandemic, National Boards issued guidance to their registrants encouraging them to protect themselves and their patients by being vaccinated. However, none of the documentation issued by the National Boards or Ahpra made vaccination mandatory. COVID-19 vaccination is or has been mandatory for certain types of health workers (whether registered or not), such as hospital workers. However, these requirements apply under state and territory Public Health orders and in some cases employer policies, rather than National Board issued directives.
References:
Leslie, K., Bourgeault, I.L., Carlton, A-L., Balasubramanian, M., Mirshahi, R., Short, S., Carè, J., Cometto, G., & Lin, V. (2022). Design, operation and strengthening of health practitioner regulation systems: A rapid integrative review. Human Resources for Health. https://doi.org/10.21203/rs.3.rs-2370701/v1
Lloyd, I., Steel, A., Wardle, J., & (eds.). (2021). Naturopathy: Practice, effectiveness, economics & safety. World Naturopathic Federation. https://worldnaturopathicfederation.org/project/health-technology-assessment-naturopathy/