Ahpra notifications on notice

With aesthetic medical practitioners on high alert after the recent advertising bans, understanding Ahpra’s complaints process – and its potential distressing impacts on mental health – becomes even more important.

In April this year, Ahpra announced the completion of its 200th cosmetic surgery and cosmetic practices notification about practitioners, just 18 months after the regulator established the Cosmetic Surgery Enforcement Unit as part of the continuing crackdowns on the industry.

While safeguarding patient safety and public trust is the paramount priority, Ahpra’s process of handling complaints and notifications has come under scrutiny over the past few years due to the immense psychological toll that regulatory investigations can inflict upon those under the microscope. International research supports this, with studies finding HCPs involved in such a process can experience heightened levels of distress, anxiety and shame, which impacts their personal lives and their families, as well as their professional identity and practice.^1,2

Identifying and minimising distress in practitioners involved in an Ahpra complaints process has become, in some cases, a matter of life and death. In 2023 Ahpra disclosed alarming study findings that revealed 16 health practitioners under review from Ahpra took their own lives during the period from January 2018 to December 2021, while four more attempted suicides or acts of self-harm during this time.

Shortly after the study was published in 2023, Ahpra committed to ‘major regulatory reforms’ in its notification process. The regulator has made inroads into a more humane approach to regulation³ but, in 2024, concerns persist regarding potential shortcomings of the notifications process, including procedural fairness and the impact on practitioners’ mental wellbeing.

Ahpra’s notification process

Ahpra’s primary mandate is to protect the public by ensuring that registered health practitioners meet national standards. When a complaint or notification is made against a practitioner, Ahpra is legally bound to assess and investigate the matter to determine if there has been a breach of these standards. Key steps in this process include:

• Initial assessment: Complaints are initially assessed to determine if they fall within Ahpra’s jurisdiction.
• Investigation: If the complaint warrants further examination, Ahpra conducts an investigation, which may involve gathering evidence, interviewing witnesses and consulting with experts.
• Outcome: Based on the investigation, Ahpra decides the appropriate action, which can range from no action to imposing conditions on the practitioner’s registration or even deregistration.

In Australia, registered health practitioners are regulated by Ahpra as well as 15 National Boards (the Boards) across 16 professions, as part of a national, multi-professional regulatory scheme.

Since Ahpra and the Boards are regulators, not complaint resolution bodies, they focus on whether the practitioner poses a risk to future patients. If assessed as no or low risk, the complaint may be closed quickly, often within 90 days. However, if a complaint is complex or shows potential risks with the practitioner’s performance, health or conduct, the process may take much longer, possibly up to several years, especially if other organisations like the police or courts are involved. The Boards can take various actions to address ongoing risks to the public, including placing restrictions on the practitioner’s ability to practice. In very serious cases, the Boards can refer the complaint to a court or tribunal, which has the power to cancel a practitioner’s registration.

‘Virtually daily grief’ – high-level findings from Ahpra report

Healthcare professionals often experience heightened stress, anxiety and even depression as a result of being under investigation.

The emotional toll can be severe, with some practitioners reporting feelings of shame, loss of identity and even contemplating self-harm.³

Ahpra’s own research unveiled a grim reality: between January 2018 and December 2021, at least 16 healthcare practitioners took their own lives during or immediately after being involved in a regulatory complaints process⁴. Additionally, four cases of attempted suicide or self-harm were reported during this period.

The qualitative study, led by an Expert Advisory Group that included independent experts, members of health practitioner National Boards as well as Ahpra, focused on the first-hand experience of practitioners who had been through a complaints process. The aim was to ascertain what factors are associated with the distress of practitioners when involved in a regulatory complaints process. It also sought to better understand the circumstances in which practitioners facing a complaint had attempted or died by suicide, to know whether there are things that can be done to prevent such a tragedy.

The study findings were published in September 2023 in the International Journal for Quality in Health Care and emphasised the need for a balanced model that addresses risk to patients while simultaneously mitigating the potential distress and harm to practitioners facing complaints.

‘Poor clinical performance, deliberate harm or intent to deceive must be identified and addressed in a timely, fair and robust way to address risk to patients,’ the researchers wrote. ‘However, this research adds to previous research, which point towards the need for a more nuanced and humane model of regulation, particularly in cases where there is a potentially high risk of distress or harm to practitioners facing a complaint.

‘Health practitioner regulators are mandated to protect the public; however, this does not preclude a simultaneous concern for the wellbeing of practitioners.

‘Some contributors to practitioner distress require a systemwide, preventative approach, including addressing stigma and misinformation. A more compassionate approach to regulation has the potential to improve the experience for all those involved and, ultimately, benefit patients, families, practitioners and the global healthcare system.’

The research highlighted the following key areas:

Emotional & psychological impact

Practitioners involved in the study shared that the mere receipt of an Ahpra notification can trigger a whirlwind of emotions, ranging from confusion and frustration to profound distress.

Practitioners commonly described the experience of having a complaint made about them, in and of itself, as distressing and affecting their wellbeing. The stress is exacerbated by the uncertainty and lengthy duration of the investigation process, leading to significant mental health challenges.

One HCP described it as ‘virtually daily grief but I managed it, you know. It didn’t make me sleep poorly, it didn’t give me an ulcer, but it was in the background the whole time’.

Many practitioners raised the length of time taken to close their complaint, citing the ongoing emotional and practical repercussions while the complaint was open. One participant described this as ‘it dragged on over years, so you’d literally be sitting in a cold sweat every day, just looking through emails waiting for the next message to come from Ahpra, which was invariably bad news’. Another said, ‘… I’m sure you’ll hear from most people, the most significant stress is in the waiting’.

Perceived bias & distrust

According to the published report, many practitioners perceived a bias in Ahpra’s handling of complaints, feeling that the system was skewed against them. There are reports of practitioners believing that Ahpra sides with complainants without thorough scrutiny of the complaints’ legitimacy.

Others described the complaint about them as unjustified, minor or undeserving of investigation.

Distrust of Ahpra was reported, often described in the context of their view of the overall unfairness of the complaint being accepted at all.

One practitioner shared: ‘Our lecturers always warned us about Ahpra notifications … in my mind it was always like this kind of scary thing. I was scared that Ahpra would just immediately take the patient’s side and then kind of gang up against me.’

Communication issues

A common criticism was the lack of transparent and timely communication from Ahpra. Practitioners reported experiencing delays in responses, unanswered calls and emails, and a general lack of information about the progress of their cases.

Study participants’ concerns were linked to uncertainty and confusion about the process, unclear timelines and no indication of likely outcomes. One practitioner said: ‘It seemed that there was no way to understand when or what was happening in the background’.

The perceived lack of responsiveness contributed to the sense that the process was out of their control. ‘Sitting around not knowing and waiting for an email, was … absolutely gut-wrenching, you know?’ said one study participant.

This generated a fear of the unknown, with practitioners not knowing where it was going to end and unable to avoid assuming the worst-case scenarios. Another commented, ‘It was one of those frustrating things where everything was not directly with anyone. So, anything you did had to be either through email and then you had to wait for the response. And so, it’s frustrating ‘cause it wasn’t immediate. You could not get, you know, everything out’.

Participants consistently reported that better communication, for example, if they had been given some early indication about how serious the complaint was and whether a serious regulatory outcome was likely, would have improved their experience considerably.

Impact on professional practice

According to the report, many practitioners saw one complaint effectively negating years of good practice and thus casting a shadow over their entire career. ‘… Somebody puts in a complaint, and the 10 to 12 years of knocking yourself out is completely irrelevant’, said one practitioner.

‘Major regulatory reforms’ to Ahpra’s notification process

The Expert Advisory Group made 15 recommendations and proposed 33 actions. All have been accepted. Some actions are already being implemented. Other actions build on work already underway to humanise the experience of practitioners being involved in a regulatory process. Ahpra says recommendations will be implemented progressively over 2023–25, and some recommendations will require the contribution of partners and other parties.

Commitments include reducing investigative timelines, providing regular, informative updates to both the notifier and practitioner, helping at-risk practitioners to access professional support, supporting unwell practitioners more closely, offering peer-support services to practitioners, and improving organisational (Ahpra) knowledge.

A dedicated Health Management Team at Ahpra, established in July 2022, to better support practitioners with a health impairment has already contributed to a significant decrease in resolution times, from 265 days to 125 days.

‘The findings of this research are deeply confronting – but we commissioned it to learn and do better,’ Ahpra CEO Martin Fletcher said at the time.

‘We want to clearly understand the pressure points in our processes that cause the greatest distress and change them. We want to ensure that mental health safety is a thread that runs through all our essential regulatory work.

‘We are trying to increase the sensitivity of our approach, to strike a better balance between effective regulation that protects the public, and due care and respect for the practitioners involved in our regulatory processes who are often facing complex health and life challenges.’

The Medical Board of Australia Chair Dr Anne Tonkin said that patient safety remains a priority. ‘At the same time,’ she continued, ‘we must do all we can to ensure our processes don’t make it harder for practitioners than the fact of regulatory scrutiny already makes it.’

Complaints about notifications jump by 39%

Despite ‘major changes’ to the way it manages notifications, Ahpra has seen a sharp increase in complaints regarding its notification process. According to the National Health Practitioner Ombudsman (NHPO), complaints about notifications have surged by 39% over the last reporting year (2022-23), despite an overall reduction in complaints about the regulator.

The NHPO’s annual report, released late last year, highlights a troubling rise in complaints related to the fairness and process of handling notifications. The most common complaints were that a decision made about a notification was unfair or unreasonable (from 153 issues in 2021-22 to 227 issues in 2022-23) and that the notifications process was unfair (from 46 issues in 2021- 22 to 88 issues in 2022-23).

‘We continue to explore the causes of these increases,’ the NHPO report states. ‘It is important that Ahpra’s attempts to reduce the length of time taken to manage notifications do not lead to negative results downstream.’

More health practitioners, up 27%, approached the NHPO in this reporting period, suggesting that this increase could indicate a growing awareness of the NHPO’s role in handling grievances against Ahpra. However, most issues raised about the handling of notifications were from the individuals who initially made the complaints.

Despite identifying some concerns with Ahpra’s new triaging model, the NHPO acknowledged the impact of the regulator’s efforts to cut the length of time to resolve notifications. The number of complaints linked to delays fell to 92 from 110. ‘Although there was an increase in complaints that related to notifications, it’s important to note that last year we received 9,706 notifications about 7,970 practitioners, and closed more than 10,500 notifications,’ a spokesperson for Ahpra and the National Boards told newsGP⁵.

‘It is reassuring to note that the vast majority of complaints referred to the NHPO are closed with no further action required.’

They also noted positive changes already made to the way notifications are managed: ‘We increased resources focused on those issues we assess as posing a significant risk to the public. Through the introduction of a revised case-management process, we better identified low- risk notifications suitable for an early determination, while referring higher-risk notifications to our new strengthening practice team.’

Vexatious complaints an ongoing issue

The NHPO’s report also highlighted the alleged misuse of the Ahpra notifications process through vexatious complaints. According to the NHPO, 44 complaints, including 41 from health practitioners, alleged that Ahpra had failed to identify a notification as vexatious during the 2022-2023 reporting year. Of these, 16 cases involved regulatory action against the practitioner’s registration.

The Ombudsman has pledged to review the processes surrounding vexatious complaints, aiming to ‘strengthen protections against the use of the notifications process to cause harm, while ensuring that the process remains open and accessible to notifiers raising concerns about patient safety’.

The RACGP has highlighted the burden of trivial complaints, with Vice President Dr Bruce Willett sharing his personal experience of a 10-month ordeal to resolve a frivolous complaint against him⁶.

Another GP, who battled Ahpra for two years, is calling for sweeping changes to the watchdog. Reported in newsGP⁷, for this GP the process began in 2022 when he was the subject of a notification from a fellow healthcare professional following a conflict over a medication prescription, which resulted in an investigation by Ahpra.

The doctor felt unsatisfied with the Medical Board’s handling of the incident and took the case to the NHPO, citing concerns over a lack of scientific evidence made available to Ahpra’s decision-makers.

‘Over the next few years, I took it on as something which needs to be put right,’ he told newsGP. ‘My intention now is to shed light on the importance of holding regulatory bodies like Ahpra accountable for their actions.

‘It is crucial for doctors and other professionals to feel empowered to speak out and file complaints against Ahpra when they believe they have been wronged by regulatory authorities.’

Two years after the incident began, a leaked document from the NHPO found the handling of the notification ‘could have been better’ and undertaken in a ‘timelier manner’. It highlighted concerns that Ahpra and the Medical Board’s notification was vexatious and should have been explored more thoroughly.

‘Please, do not ever give up if you feel you’ve been wronged; take it up and go through the motions like I did,’ said the GP. ‘By doing so, we can contribute to the improvement of Ahpra’s services and ensure a fair and just system for all healthcare practitioners.’

The increase in complaints about Ahpra’s notification process underscores the need for ongoing reforms. While the regulator has made strides in improving its processes, the concerns raised by healthcare providers highlight the importance of transparency, fairness and timely communication. AMP